The most common breast augmentation technique uses the inframammary fold or breast crease as the entry point of implants. For most patients, the incisions fade into a fine, barely noticeable scar about a year after surgery.
Another common approach is the peri-areolar in which a small incision along the lower end of the areola is used, specifically the sharp demarcation between the areola complex and the adjacent normal skin.
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For patients who are deemed at increased risk of aggressive scars—such as dark-skinned Asians, Hispanics, and Hispanics—the peri-areolar technique may not be ideal, explains breast augmentation Los Angeles expert Dr. Tarick Smaili.
However, there are other variables, such as the implant size and filler material, that should be taken into account as well to determine the most ideal entry point, says the renowned plastic surgeon.
A possible approach for patients concerned with aggressive scarring is to place the incision within the armpit’s natural skin fold, an area that is innately resistant to aggressive scarring.
In the past, the trans-axillary or “through the armpit” technique rarely used [prefilled] silicone implants that would require longer incisions. Saline implants, meanwhile, were considered the ideal choice because they were only inflated with saltwater solution once inside the breast pocket.
But with the introduction of Keller Funnel, a cone-shaped device that is squeezed to push the implant forward into the pocket, it has become easier to use silicone implants via trans-axillary approach. With this technique, there is no visible scar on the breast skin and the patients enjoy a more natural shape and feel.
Meanwhile, patients with a darker skin might also benefit from the inframammary or “through the breast crease” without having to worry about visible scars. But this is only true for women with a defined or deep fold or some slight sagging, which can hide any potential scar.
Another possible compromise is to position the scars on the underside of the bulge of the lower pole so they remain hidden even when the patient’s bikini top accidentally rides higher.
Aside from choosing the correct entry point based on the patient’s anatomy and propensity to thick scars, proper wound care and scar treatments such as silicone sheets and creams can further lead to finer, less noticeable scars.
And lastly, the “premature” scars should not be exposed to the sun for up to a year postop to prevent hyperpigmentation or hypopigmentation (i.e., abnormal pigmentation of the skin due to the effects of ultraviolet radiation).
Several factors will determine the “ideal” breast implants, such as your underlying anatomy—i.e., skin quality, breast width, chest measurement, thickness of tissue, and natural projection of your breast.
An equally important variable is your motive and expectation from breast augmentation surgery.
It is important to note that the unique traits of gummy bear implants could make them ideal for one patient, but a poor choice for someone else due to her anatomies and other “relevant” factors.
But before we explain the characteristics that make someone a good or bad candidate for gummy bear breast implants, it is imperative to describe first how its filler material differ from the fourth generation or “standard” silicone implants.
The chemical structure between the standard silicone implants and gummy bear implants is pretty much the same, although the latter have a silicone gel that is more cohesive to the point that it resists the effects of gravity, thus they are also referred to as form-stable implants.
When cut in half, the silicone gel of gummy bear implants remains in place, almost like a soft jelly or extremely thick glue. For this reason, proponents believe these implants have almost eliminated the risk of rupture or leak, if not significantly reduced.
By law, candidates for gummy bear implants and standard silicone implants should be at least 22 years. Their higher age requirement (the minimum age for saline-filled implants is 18) is due to the perceived risk or possibility of gel leak.
Another requirement is that you should have a good amount of skin firmness to achieve good results from gummy bear implants. If there is some extra skin around the breast or your nipples are too low, they could further aggravate the drooping appearance and breast tissue laxity.
In general, all silicone implants are favorable if you have very little breast tissue. Saline implants, meanwhile, might lead to a globular look and water balloon like “feel” for someone with limited “coverage” due to the nature of their filler material, which is nothing but a sterile solution of saltwater.
Due to the form-stable nature of gummy bear implants, they must always come in anatomical or teardrop shape. For this reason, they might not be a good choice if you want an exaggerated fullness in the upper breast pole, which can be achieved by using round implants that in essence are like flat spheres.
Basically, there are two types of breast implants used in cosmetic augmentation and reconstructive surgeries: saline implants and silicone implants whose name is based on their filler material.
However, silicone implants are further categorized into two groups based on how “thick” their silicone gel is.
To help you understand the two types of silicone breast implants, i.e., cohesive and gummy bear type, experts from the California Surgical Institute provide their simple explanation.
- Cohesive silicone gel implants. They are also referred to as fourth generation silicone implants whose cohesive filler material is notably thicker compared to saline or saltwater solution. “Cohesive” means the molecules have a strong link to each other.
Their filler material is comparable with a thick transparent glue, although when touched the implants feel like a soft jelly.
Compared with saline implants which are rolled up into a cigar shape and pushed toward the pocket “empty,” fourth generation silicone implants require a longer incision (around 4 cm if they come in larger sizes). However, it is possible to shorten their scars with the use of Keller Funnel which is a device closely resembling a piping bag.
The “inside” of Keller Funnel is lubricated to make sure the silicone implants can be easily and quickly propelled into the pocket, thus minimizing surgical trauma and reducing the length of scars. Studies have suggested that they can also reduce the incidence of capsular contracture or scar tissue hardening.
But compared with gummy bear implants, cohesive implants generally require shorter incisions.
As of this writing, cohesive silicone implants are the most commonly used breast implants in cosmetic breast augmentation.
- Gummy bear implants. In 2012, the US Food and Drug Administration approved the first gummy bear implants, which in essence are fifth generation silicone implants. While they are “structurally” the same with their predecessors, their silicone gel is more cohesive to the point that it is form stable.
These form stable implants are shaped like a teardrop in which most of the volume is at the bottom. For this reason they are particularly helpful in breast reconstruction, although they are now increasingly becoming popular in cosmetic breast augmentation surgery as well.
Unlike their predecessors, gummy bear implants are not available in round shape lest they result in globular, unnatural appearance.
Because this newest implant type only comes in teardrop shape, they have a textured shell designed to promote tissue adherence. The idea is to avoid flipping over, causing visible breast deformity.
Asian rhinoplasty or cosmetic nose surgery performed on patients of Asian background often involves augmenting the low or near absent dorsum or bridge. But to achieve a more streamlined appearance, the mid section, nasal tip, nostrils, and/or overall profile must be also enhanced.
According to California Surgical Institute website, the vast majority of rhinoplasty patients will require all or most of the aspects of their nose to be reshaped. Only a few people can benefit from an “isolated” procedure, e.g., removing the dorsal hump or augmenting just the bridge.
To augment the Asian nose, most Beverly Hills plastic surgeons prefer the use of cartilage grafts to synthetic implants such as solid silicone. The former is believed to provide a more natural result because the patient uses his own tissue, which can be harvested from the septum or wall dividing the nostrils, ear, or rib.
But in Asia, the use of silicone implants in augmentation rhinoplasty remains popular. First and foremost, they are well tolerated by the Asian nose because of its thick nasal skin, thereby reducing the risk of implant protrusion or visibility—a problem commonly encountered with the use of artificial prosthetic in Caucasian patients.
As a readily available material, nose surgery via silicone implant is usually quicker than rhinoplasty through cartilage graft techniques that may entail a separate procedure to collect the tissue from the donor site.
Silicone implants might also be a good option if one needs larger augmentation.
However, the disapproval of many US plastic surgeons with the use of silicone implants and other synthetic implants has its own valid reasons. Medical literature has suggested that around 10 percent of patients over a 10-year period will require removal of these prostheses usually due to extrusion, displacement, and over prominence.
Some surgeons avoid the use of silicone implants altogether, arguing that in most cases they will cause the skin to thin out that they poke through it.
The rate of infection is also higher with the use of silicone implants and other artificial materials compared with cartilage grafts.
The consensus is that using the patient’s own tissue rather than silicone implants to augment the Asian nose is generally considered as a better option. Oftentimes, there is an adequate amount of cartilage in the nasal septum, thus a separate procedure is not needed.
But if there is a deficiency in septal cartilage, grafts are harvested elsewhere such as the bowl of the ear, without affecting its function or outside appearance or causing visible scars. Rib cartilage is another good option in augmentation rhinoplasty, although it is a more challenging technique since it is hard to reshape and has the tendency to warp over time.
Breast implants are often used in cosmetic breast augmentation in which the goal is not just to increase the “cup size” but also to reshape it in a way that it looks natural and proportionate. Some women also ask for these prostheses to achieve more fullness in their upper cleavage, which sometimes deflate after pregnancy or weight loss.
One of the most common concerns of women considering getting their breasts augmented is the unnatural feel and look.
Contrary to popular belief, breast implants are hard to detect by touch especially if the patient has a good amount of coverage to begin with, i.e., breast tissue and fat, as suggested by renowned Beverly Hills plastic surgeon Dr. Tarick Smaili.
In case that you have some deficiency in breast tissue, Dr. Smaili recommends silicone breast implants to compensate for the lack of coverage. These prostheses are prefilled by their manufacturers with a highly cohesive medical-grade silicone gel that “behaves” and feels like natural tissue.
Saline implants, meanwhile, are positioned inside the “pocket” empty before they are inflated by plastic surgeons with a predetermined amount of saline, or sterile salt water solution. For thin and small-breasted women, Dr. Smaili says they could lead to a more globular look and more palpability as well.
Aside from using silicone implants to make the breasts feel natural, the renowned Beverly Hills plastic surgeon also positions the devices underneath the thick layer of muscle—a technique called submuscular—to further prevent them from being detectable by touch.
The opposite of submuscular, called subglandular, may result in more palpability especially in athletic and naturally thin women, he warns. In this technique, the implants are settled above the muscle, with only the breast tissue, fat, and skin enveloping them.
Another way to make your postop breasts feel natural, Dr. Smaili recommends choosing a small to moderate augmentation so your underlying anatomies will not be stretched beyond their innate limits.
With overlarge implants, or a size that overwhelms the amount of soft tissue, Dr. Smaili warns that palpability is a huge concern, in addition to higher risk of visible rippling, implant displacement (e.g., bottoming out and lateral malposition), and results that look fake overall.
Despite the use of conservative-sized silicone implants positioned underneath the muscle, Dr. Smaili says that some patients remain susceptible to more palpability and visible rippling due to their anatomies or previous surgeries (e.g., mastectomy), making the use of soft tissue thickener such as fat graft and acellular dermal matrix ideal or even necessary.