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breast implants

Deciding to undergo a breast augmentation is only the first step in the cosmetic surgery process. There are many choices patients will need to make, including the shape, size, and type of procedure.

It used to be that silicone or saline implants were a woman’s only options, but now there are molded shapes, such as the “gummy bear” implant, or even the possibility of transferring the patient’s own fat from other areas of the body to the breast. We interviewed five board certified plastic surgeons to find out which option provides the most realistic results.

plastic surgeons, breast augmentation
Drs. Kurkjian, Marosan, Doft, Ellenbogen, and Rubenstein

Dr. Jon Kurkjian

Fort Worth, Texas

  • American Society of Plastic Surgeons
  • American Board of Plastic Surgery
  • American Society for Aesthetic Plastic Surgery

What looks and feels the most natural, fat grafting or implants?

Fat grafting is probably the most natural breast augmentation method. However, you can only achieve mild increases to the breast using fat alone. Breast implants are required to gain more than one cup size. A composite procedure using fat grafting and silicone implants can give you the most natural results when trying to achieve a significant increase in size.

Keep in mind that if you inject fat and the fat dies, it can interfere with the ability to monitor breast cancer, which is diagnosed in 1 in 8 women. As a best practice and depending on their age, women should get a mammogram before fat grafting so the current state of the breasts is known.

On silicone vs. saline

I think that silicone implants look and feel more realistic. The difference between silicone and saline becomes less important when the patient has a significant amount of breast tissue to cover the implant, which is typically the case when the tissue pinch test is more than 3 cm. In other words, if you’re going to feel the implant through the skin, silicone is preferred.

On gummy bear vs. silicone

The gummy bear implant is a specific kind of silicone implant, which is really a cohesive gel-shaped device. I think it shows significant advantages in terms of maintaining the position and shape of the implant over time. However, shaped implants will rotate in certain cases, and recent evidence indicates that may occur more than we originally thought.

Dr. George Marosan

Bellevue, Washington

  • American Society of Plastic Surgeons
  • American Society for Aesthetic Plastic Surgery
  • International Society of Aesthetic Plastic Surgeons
  • American College of Surgeons Fellow

Fat grafting vs. implants: which is most natural?

Fat grafting is obviously more natural because it’s your own fat, so you don’t have to worry about implant failure or exchange, but normally you can’t increase more than one cup size with one fat transfer procedure.

If the patient wants a significant volume enhancement, then implants are more predictable. The downside is that it’s recommended that they be replaced every 10 years, although in my opinion implants can be kept longer if nothing is wrong with them.

Achieving a natural look with implants comes from choosing the appropriate size based on the patient’s measurements, tissue thickness, chest wall symmetry, and breast symmetry.

gummy-bear breast augmentationWhat are your thoughts on gummy bear implants?

There’s been a lot of marketing done for gummy bear implants, since it’s a relatively new and allegedly more natural-looking option. I continue to favor round silicone gel implants. They still give the best results – I think 90 percent of augmentations are done with them.

At a plastic surgery conference panel discussion, surgeons couldn’t tell the difference visually between gummy bear and round silicone implants – 80 percent of the time people guessing got it wrong. Also, when a woman lays down her breasts tend to go to the sides. Since gummy bear implants are firmer than silicone, the implant sticks up on the chest wall, so it’s not as natural-looking. Another problem with shaped implants is that they can twist, turn, and slip, causing changes the shape of the breast.

Dr. Melissa Ann Doft

New York, New York

  • Clinical Assistant Professor of Surgery, Weill Cornell Medical School
  • American Board of Plastic Surgery
  • American Board of Surgery

Which is best: fat grafting or breast implants?

They’re so different that you can’t really compare them. They’re two different operations. Fat grafting might be the most natural thing, but it’s not the most predictable. With implants you know what they’re going to look like; they provide a foundation to a nicer, fuller upper-cleavage line. With fat grafting, it’s unpredictable how much fat will survive and what shape the breast will take. It’s also not an option for every patient, such as patients with very little fat.

There are too many negatives to fat grafting for it to be the leading breast enhancement method. A nice way to use it is in combination with implants. In fact, many patients who choose fat grafting end up adding implants later.

What percentage of the fat survives after grafting?

Published studies show that 30 to 50 percent of the fat will survive, but you don’t really know, so most doctors will overfill or fill until it looks perfect. Often you need multiple surgeries, which is something to consider with fat grafting.

Saline vs. silicone implants: which do you prefer?

Almost all of my patients have silicone implants. I think they feel much better than saline. They’re much softer, have a different consistency, and aren’t as heavy. The only times I’ll use saline is if the patient is under 22 years old, or if she is really nervous about putting silicone into her body. Also when price is a concern, saline costs half as much as silicone.

Round silicone vs. gummy bear: which feels most natural?

I think silicone has a softer feel to it, so that’s what I usually use. The traditional gummy bear implant is much harder. In my opinion gummy bear implants may be better suited for breast reconstruction procedures, since they’re useful for creating a shape where there isn’t a breast. Anecdotally, in the study to get the gummy bear implant approved, some mastectomy patients had them removed because they felt they were too hard.

In a standard, not-reconstructive breast augmentation you already have a breast there and you’re just trying to enhance the volume. I often use Sientra implants – they’re almost in between the gummy bear and round silicone: they’re so soft they feel like a traditional implant, but aren’t as hard as the gummy.

Dr. Richard Ellenbogen

Beverly Hills, California

  • Diplomat of the National Board of Medical Examiners
  • Diplomat of the American Board of Facial Plastic and Reconstructive Surgery

Which do you prefer – fat grafting or breast implants?

I don’t find fat grafting as good as implants. The most important thing in plastic surgery is to know how things will last down the line. Implants have a 40-year history and everybody knows everything about them – the good, the bad, and the ugly. With fat, we don’t. We’re just starting to get statistics for fat grafting, such as where it dissolves, forms cysts, and causes pain. The good thing about fat grafting is that you don’t have something foreign in your body, and it does a nice job for breast reconstruction. The bad is that it will decrease in volume, form cysts, result in retractions of the skin, and grafted fat gains weight when you gain weight. You often have to have more fat put in or taken out.

Personally I prefer implants and accept their shortcomings. The average implant is 300-350 cc in California. To duplicate that you need 500 ccs of fat, which is a pound. Many women don’t have that amount of fat, so they have to have implants. For extremely thin women, I like to do implants along with fat grafting.

Which feels the best?

I think implants are the gold standard, and fat grafting comes in second place. Fat in the breasts doesn’t feel totally like a breast – it has a rough character to it.

Which type of implant do you prefer?

Although I won’t use them on athletic women, I like saline implants because they’re more bouncy. When you lay down they go flat, you can put them into a small incision, and they’re adjustable.

That being said, it’s not the technique that matters most, it’s the technician. The type of procedure isn’t as important as the surgeon’s skill at performing it. Some doctors are good at one technique, and others will get perfectly good results with another.

Dr. Adam Rubenstein

Aventura, Florida

  • American Society of Plastic Surgeons
  • American Society for Aesthetic Plastic Surgery
  • International Society of Aesthetic Plastic Surgery

Which do you think is the most natural looking: fat grafting or implants?

I don’t think there’s one straightforward answer – it depends on the tissue the patient has to begin with, and what the patient is trying to achieve. There are so many variables. There are things you can do with fat grafting that you can’t do with implants, and vice versa.

What can you do with fat grafting that you can’t do with implants?

Fat grafting can be used anywhere it’s needed when you’re trying to change the shape of the breast a little bit. For example, if you have a breast that’s too full on top and not full enough on the bottom, you may have an easier time distributing fat with grafting. You can’t get the same amount of augmentation and fullness using fat grafting, though. If you’re trying to create a much fuller breast overall, you’re better off using an implant.

Which has a more natural feel?

It depends upon the change you’re trying to make. In general, fat grafting has a little advantage because it’s your natural tissue, so it doesn’t get better than that. But if you’re trying to make your breasts a lot bigger, fat grafting isn’t even an option. Fat also has the potential for necrosis, and can form hard nodules.

Implants have an advantage for achieving larger volume, and the difference in feel is going to be negligible if you’re starting with a larger breast and just trying to add some volume – the more natural breast tissue there is sitting on top of the implant, the less of a difference there will be in terms of feel.

What do you think of composite procedures using silicone and fat grafting?

A composite is used when you need fat grafting to change the shape, but also want significant volume increase. It’s two procedures, and each procedure has its own risks, although they’re pretty small. It’s only preferable if you need it.

When it comes to saline vs silicone implants, which looks and feels more natural?

In my opinion, silicone is going to feel more natural. It’s softer and flows more like a real breast. Generally speaking, I recommend silicone to the majority of my patients.

Is there a time when you recommend saline?

Some patients aren’t comfortable using silicone based on the old FDA restrictions that have been lifted and are no longer relevant. Saline implants are also less expensive. Another instance when saline has an advantage is when the patient wants the breast to have a really full, round, “high profile,” because saline implants keep their shape a little more and don’t tend to flow like natural breast tissue as much. When you’re trying to look “done,” so to speak, and are trying to have a round firm upper pole, saline is better.

What about round silicone vs. shaped (AKA gummy bear)?

Shaped implants are very good for reconstructive purposes, and on occasions are good for cosmetic applications depending on the patient’s breast, but I personally prefer round implants for cosmetic use in general. Silicone doesn’t stay round – it flows and becomes teardrop-shaped when you place it in the breast.


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About The Author

Articles by

Liane Yvkoff is a contributing lifestyle writer for Zwivel. She has contributed to Forbes.com, Men’s Journal, Women’s Health, Popular Mechanics, CNN.com, CNET.com, and several publications for which you must show ID to purchase.

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