The 3 Most Important Decisions for Breast Augmentation

how to decide between silicone vs saline breast implants, and under or over the muscleThere’s a lot to think about when considering breast augmentation surgery, and it’s easy to become overwhelmed with the amount of information that you’ll pick up during the consultation process, especially if you’re seeing multiple doctors. None of these decisions are trivial though, so we want to try to help by sorting out the main decisions that have the most impact on the final result. Keeping things organized and simple is the best way to make a good decision and give yourself the best possible chance of getting a result that you’re in love with!

#1. What type of implant is best for you?

  • Silicone vs Saline: Silicone breast implants are the gold standard for breast augmentation surgery nowadays because they produce the most natural look and feel, and also because they have less complications than saline implants. Saline implants have a very limited role in the hands of breast implant specialists, so if the information you’re reading online conflicts with that, please make sure your sources are current (many of them are not), and schedule a personal consultation to discuss the issue with a plastic surgeon who specializes in breast implants.
  • Implant Style: Breast implants come in four different styles: low profile, moderate, high, and ultra-high. This is probably the most important decision to be made. The profile of the implant plays the biggest role in how an implant looks after surgery. Most women prefer the moderate profile implants since they offer the best balance between a natural look and a sexy look.
  • Implant Shape: You have a choice between round implants and teardrop shaped (also known as anatomic) implants, but this decision is not quite as important as the implant profile. Round and teardrop implants each have advantages and disadvantages, so if you are interested in the teardrop implants make sure to ask your plastic surgeon about them.
  • Implant Surface (Shell): The surface on the implant shell is an important choice that is unfortunately left out of many breast augmentation discussions. Breast implant shells are manufactured with smooth surfaces and textured surfaces. The smooth surface implants are a little softer, and look better sooner in the recovery period, but they probably age a bit faster because they are subject to the forces of gravity. Textured surface implants adhere to your natural tissues so they resist gravity better than smooth surface devices, and they also feel a bit firmer (which may be a positive or a negative depending on how dense your breast tissue was when you were younger… young, dense, breast tissue feels more firm than older tissue, so many women actually prefer the additional firmness of the textured surface).

#2. Implants under or over the muscle?

  • Under the Muscle: Implants that are under the muscle (sub muscular) have a more natural slope in the upper part of the breast, have less visible rippling, and have less complications like capsular contracture. Submuscular placement is the best decision for most women, so if you have any concerns about this method, make sure you fully understand the disadvantages of going over the muscle.
  • Over the Muscle: The only women who should consider placing the implants on top of the muscle are: 1) women who are trying to get as much lift as possible without actually having a breast lift procedure, 2) professional athletes and fitness competitors who make a living with their muscles. If you are not in either of these groups, the best decision is to place the implants under the muscle.

#3. Where do you want the scar to be?

This is perhaps the most difficult decision because there is quite a bit of conflicting information on this topic. There are four basic incision choices for breast augmentation:

  • incision choices for breast augmentationInframammary (under the breast in the fold): Overall, this is the most popular incision choice… for a good reason. Inframammary incisions have been shown to lead to the lowest risk of capsular contracture, and offer the quickest recovery. They can also be very well concealed in the fold so that they are nearly invisible.
  • Periareolar (around the bottom half of the areola): Periareolar incisions can also be very inconspicuous when they heal well, but they can also be very visible if they don’t. In addition, recent research suggests that the risk of capsular contracture is higher with periareolar incisions so this decision needs to be carefully weighed against any possible cosmetic benefits.
  • Transaxillary (in the armpit): The transaxillary incision can be very well concealed if it heals well, but implants placed through this method take longer to heal and have a higher chance of migrating upwards over time. Revisional procedures to shift implants downwards when they heal too high on the chest are more common with this technique, so the hidden scar may come at a cost if the implants don’t heal in the right position.
  • Transumbilical (through the belly button): Most plastic surgeons who specialize in breast augmentation agree that this technique should not be performed any longer because the revision rate is unacceptably high for problems with poor implant positioning and bleeding, because silicone implants cannot be used through the belly button, and because the transumbilical incision leads to a significantly higher rate of complications.

Remember, your incision choice is not only a cosmetic issue. Each incision has a defined set of benefits and risks that goes beyond the simple question of where you want the scar to be, so don’t take this choice lightly. We recommend the inframammary incision to most of our patients because it has the best balance between a good cosmetic appearance that is well hidden, and the lowest risk of complications like capsular contracture and implant migration.

As you can see, there is a lot more that goes into an outstanding breast augmentation result other than size. Making an educated decision about the implant type, style, surface, and incision has a more significant impact on the final outcome, and once you have those choices nailed down, the size becomes an easy decision, especially with the guidance of an experienced plastic surgeon who specializes in breast implants.

If you would like to learn more about everything that’s involved with breast augmentation surgery, you can give us a call at 917-703-7069 to schedule a personal consultation, or visit our website that is devoted exclusively to cosmetic breast surgery

Nicholas Vendemia, M.D.
Plastic Surgeon New York

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Photo Credit:, Manhattan Aesthetic Surgery LLC