Quick list of relative merits between saline and silicone:

• If the cohesive silicone gel shell ruptures, there will be no leakage or deflation.
• Silicone implants are sealed at the factory, and therefore are not an option for the TUBA (belly button) procedure. It’s unclear whether they’re an option for the transaxillary (armpit) procedure.
• Saline implants can be overfilled. If you prefer the “fake look”, this should be your choice.
• If a saline implant shell ruptures, the deflation can be slow, or it can be quick.
• The Becker implants seem to be a compromise, by being a hybrid of saline and silicone (separate chambers, where the saline bladder is inside the silicone bladder). Some swear this is the best option out there. However, some sources have given their (professional) feedback of this particular implant which has been less than stellar (ie, the fill port valve has been known to leak). Note that this info might be outdated; that said, caveat emptor. Check with your surgeon; if he prefers them, then chances are he’s had great success with them.

_{A solid, flexible silicone 1) shell filled with silicone gel.}

Pretty simple really, until you stop to consider that there’s the original silicone gel (the type which originally got banned by the FDA) and the newer cohesive gel (a.k.a. “gummy bear”) implants. It’s commonly believed that the original formulation still feels the most natural out of all implant designs. However, the newer cohesive gels have been found to be remarkably realistic; they’re nowhere near as firm as Jell-O, and yet if you were to cut a wedge out of one of these implants, the gel would stay in place. That’s right, the gel won’t ooze out like Jell-O on a hot summer day. Hence the name “cohesive”, because it has a strong tendency to remain whole.

_{Two views of cohesive gel implants, cut open.}

• http://www.breastconsult.com/types-of-breast-implants.html
• http://www.justbreastimplants.com/implants/cohesive_gel_advantages_disadvantages.htm
• http://www.breastimplants411.com/dbii/articles.asp~Article_ID=79
• http://www.truedoctors.com/body_implants.htm

A solid, flexible silicone shell filled with saline 2). Yes, you read that right; if you thought that a saline implant had no silicone content whatsoever, you’d be partly right. The filler has no silicone, but the shell is a silicone elastomer, the same material which is commonly used in other implant surgeries, such as the type of implant when one wants to improve on a receding chin (ie, chin implant).

These can be factory-sealed (depending on the implant model), but are most commonly filled during surgery. The implants which are filled during surgery have a clever valve design which permits easy filling and fine tuning of the fill volume during surgery, but once the surgeon is satisfied with the fill volume, a simple tug on the fill tube allows the valve in the fill port to close up rather securely.

• Silimed - See also Silimed_Large_Mammary_2006 for a recent table (courtesy of notasurgeon from the BEA)
• Inamed (formerly McGhan)
• Eurosilicone web site - see also the Eurosilicone wiki page
• others? (citations needed)

Check out the Newbie Info page for more details.

Wanting to tell your surgeon “Make me as big as you possibly can!” is a lofty goal. Be aware that there will be trade-offs if you (and your surgeon) follow through with this.

The bigger they are:

• the more weight you’ll have to contend with
• the more likely you should wear a bra all the time (to fight the effects of gravity)
• the more likely you’ll feel a greater strain on your back
• the more likely your bra will dig into your shoulders (which can be quite dramatic, if you choose the wrong bra)
• the more likely you’ll attract public attention
• the greater the trouble you’ll have finding the right clothing to buy/wear
• the greater you will benefit from either having sewing skills yourself, or knowing someone who can do custom bras/tops for cheap

... and be prepared to go to another surgeon if you don’t like what you’re hearing. First and foremost, a surgeon wants success. Success for you means success for him. If he feels something is risky for you, he won’t take the chance, in part because he wants you to be a happy camper, but also in part because bad news travels at least as quickly as good news.

And ‘risk’ as far as the surgeon is concerned could include aesthetics. So if your surgeon seems shocked when you say you want something bigger than 500cc, or that you want something larger than a D-cup, chances are good that you need to consult with another surgeon.

That said, if you have 5 consults with 5 different surgeons, and they’re all telling you the same thing (eg, “Your body simply cannot take more than 500cc with the first surgery”), perhaps it’s time to stop and listen to them. That said, if the surgeon you’re with doesn’t want to discuss plans for subsequent surgeries, possibly trying to steer you away from the notion with comments like, “You actually like that size?”, you might want to consider finding a surgeon who is willing to work with you on your long-term plans.

How do I get in on the study?

Assuming you qualify, the best bet is to find a surgeon who is part of this study. (This goes for the silicone gel implants as well as whatever is available in the saline implants.) Trying to find a surgeon who is part of this study can be a bit of a needle-in-a-haystack if you try contacting their offices directly, unless you’ve already heard about one through a friend or friend-of-a-friend who has already gone this route. The better option is to contact the implant manufacturers directly.

• Original Silimed site - Mirror of Silimed site 3)
• Mentor USA - Mentor worldwide
• McGhan

Note that there doesn’t appear to be any direct contact links for Mentor; it seems they’d rather you call someone on the phone. Ditto with Inamed. (If you discover the link for making a request online via web form or e-mail, please update this wiki page accordingly.)

When you initiate contact, explain that you’re trying to locate a surgeon in or near your area who is participating in the 1000cc silicone (or saline, if that’s your area of interest) clinical study. Be aware that the numbers of these surgeons is a pretty short list, so even if you live in a major urban centre, don’t be surprised if the list you’re given back is one and only one name. If they tell you there’s nobody in your area, you may need to follow up and find out where the nearest one is in nearby urban centers.

• Silimed 1000cc breast implant study
  • Dr Bloom (Dallas, TX)
  • Dr Grant Stevens (Marina Del Ray, CA) - Actual patient reference
  • Dr Burt Faibisoff (Lake Havasu, AZ)

• Silimed implant spreadsheet - 4) same spreadsheet in HTML - includes sizes up to 1000cc

Post-op adjustables/expanders/expandables are a variation on the saline implant theme. The big difference is that they are designed to accomodate a gradual fill over time (post-op) to achieve a target volume. Once that target volume is achieved, the patient should plan on getting permanent implants implanted, as the expanders/expandables are meant to be temporary.

• Becker Adjustables - In particular, check out model 350-0800. See footnote. 5)
• INAMED (formerly McGhan) Expanders - In particular, check out Style 133 FV. See footnote. 6)
• Mentor Spectrum Post-op Adjustable Implants
• Eurosilicone catalogue - see also the Eurosilicone wiki page

Smooth and textured refer to the implant shell surface.

While examining a smooth implant, the surface appears and feels to be as smooth as the outside of a Ziploc bag, and pretty much as transparent.

A textured implant’s surface is translucent and feels rough to the touch. Not ‘sandpaper’ rough, more like ‘fine bumps’ rough.

One problem which crops up a small percentage of the time is (excessive) capsular contracture, the body’s natural response to dealing with a foreign object. To address this, textured implants were designed, which were found to have a lower incidence of capsular contracture. It has been said that the capsule seems to have a greater challenge forming around the implant, or that the implant’s texture seems (to the body) to be not quite so foreign.

The trade-off is that a textured implant is more likely to ripple or fold on itself than a smooth implant of the same rating and fill. Worth noting is that the incidence of capsular contracture is notably lower when the implants are placed submuscularly, and as such smooth implants become the preferred choice of surgeons. Also, it seems that the textured shell is easier to ‘feel’ or palpate through the skin.

The textured surface also seems to provide some degree of purchase for the surrounding tissues to “hold onto”, compared to that of a smooth implant. Some surgeons prefer this, citing better implant stability. Other surgeons prefer the smooth implant for the exact same reason, instead promoting free movement of the implant within the pocket.

The incision is created in the breast fold. This method can accomodate either saline or silicone implants, especially in the larger sizes.

Example here.

Incision along the perimeter of the areola. Usually located along the lower perimeter, although some surgeons prefer to do so along the upper perimeter (possibly if in combination with a crescent lift). This method can accomodate either saline or silicone implants, especially in the larger sizes.

The incision via the armpit. This method can accomodate saline implants; it’s not always whether silicone implants can be implanted via this approach; likely the biggest factor is the size of the implant. (If you know otherwise, please update this wiki.)

TUBA stands for Trans-Umbilical Breast Augmentation. Incision is done via navel. A blunt instrument is used to create a tunnel just under the skin to the inframammary position. A tube is then inserted to allow the surgeon to create/prepare the pockets to receive the implants. The empty implant is then rolled up (with fill tube attached), inserted into the tube, pushed to the far end where it is unfurled. The surgeon then adds the saline to the pre-determined size (although the surgeon may elect to put in slightly more/less as circumstances merit, usually with the goal of achieving symmetry in the breasts). Once the desired volume is achieved, the surgeon pulls on the fill tube which disconnects from the implant, and the implant’s self-sealing mechanism prevents any saline from leaking out. The surgeon then palpates and manually adjusts (ie, “fine tunes”) the implant placement. After completing the work on both sides, the surgeon removes the tube used to insert the implants, sutures the incision and places the dressing.

_{1. Subglandular (over the muscle) placement. 2. Submuscular (under the muscle) placement.}

Regardless of which incision method is used, the surgeon still needs to place the implant either over or under the pectoralis, or chest muscle. These days most surgeons prefer to implant under the muscle, as it makes for a more natural looking result. That is, the upper perimeter of the implant is much less noticeable with the muscle covering it. This is usually a consideration with leaner women or women who are starting at an A or B cup; the more natural breast tissue there is, the more successful the breast tissue alone will make the implants less obvious. Even so, more surgeons are opting to go submuscular. One trade-off of going under the muscle is that post-op recovery might take longer, or might possibly be more uncomfy for the patient. (The degree of the discomfort varies from patient to patient, so no sweeping generalizations will be made here. Best to check with your surgeon prior to surgery.)

Thought to be too risky (complications including lumpiness and calcification, making mammograms difficult), it now seems that Dr Sydney Coleman has embraced this and is getting decent results without the risk.

No news yet on whether he can take a substantial amount of fat and create the equivalent of 1000cc (or larger) implants. [Editorial comment: Unlikely, but still worth mentioning the procedure for women who might be interested.]

More citations needed here.

• String Implants (properly called PPP (polypropylene) string implants) were created by Dr. Gerald W. Johnson, M.D.P.A. Not approved by the FDA due to the costs of getting them approved. More info here.
• Here is an e-mail allegedly written by Dr Johnson to the moderator of a Yahoo group. Original BEA thread post can be found here.

Well it won’t happen in the USA. Or Canada.

However, JuliaJugs (from TOF) has been researching the heck out of this. Much of what she’s unearthed is listed below:

• You need to acquire a spool of sterile PPP string yourself. Sources/recommendations will be posted as discovered. The string is the same as is used in SURGIPRO™ MULTI-filament Polypropylene Mesh. More interesting info about the material can be found here.
• You need to find a surgeon who will do the work.
• The surgeon will need to dissect the pockets as he would ordinarily do for conventional breast implants.
• The surgeon will need to stuff the PPP string into the pockets. No details as to how much string will produce what size breasts.
• One surgeon is located in India; his name is Dr. Manohar La Sharma, his website is http://aestheticsurgeon.org. He does not advertise the string implants on his site, you just have to email him and ask him about them.
• Another surgeon is located in Thailand. Details withheld (for now), as that’s JJ’s surgeon of choice, and she doesn’t want to spook him with a deluge of PPP string BA surgery requests.

• It seems that the consumption of alcohol (esp. when combined with salt, eg, Margarita) tends to spur on the growth associated with PPP implants. If that’s what the woman wants, then great. If the woman already feels her breast size are at the limit of what she can endure, this means she needs to watch what she consumes.

Normally the body reacts to the insertion of breast implants by growing a protective layer of scar tissue over them. In a small percentage of cases, that scar capsule will grow in thickness. The net result is that the breast will end up feeling hard and the implant will appear rounder and more visible under the breast tissue.

There do seem to be ways to mitigate the risk of capsular contracture:

• Capsular contracture remains the most common implant related complication in breast augmentation and breast lift procedures involving breast implants. Dr. William P. Adams, Jr, MD is publishing a landmark study in the January 2006 issue of Plastic and Reconstructive Surgery, the premier Plastic Surgery journal in the specialty worldwide. “This study culminates the past 8 years of work we have done on capsular contracture and how we can make breast augmentation and breast implant procedures safer and better for patients” says Dr. Adams the Dallas based breast specialist. Dr. Adams and his colleagues have previously published recommendations to minimize capsular contracture using defined combinations of antibiotic solutions and refined techniques. “These previous studies were in vitro (test tube) studies and the November publication reviews the 6 year clinical results in patients using these techniques,” says. Adams, “The results demonstrate that the patients in this study had a 4-5 fold lower capsular contracture rate than the best data compiled for FDA breast implant clinical trials.”
  The benefits to potential patients for both aesthetic and reconstructive breast surgery are significant. The study also demonstrated that in addition to the reduction in capsular contracture the overall patient re-operation rates were 2.8% compared to 15-20% seen in PMA breast implant clinical trials over the past 2 decades. “Using these advances in breast implant patients can have better and safer results including reduced ... 7)

• Baker Grade I - The breast is normally soft, and looks natural. (Basically, we all have this, since we all have a “capsule”.) It is only when the capsule starts shrinking/contracting that capsule contracture occurs.
• Baker Grade II - The breast is a little firm, but appears natural.
• Baker Grade III - The breast is firm, and is beginning to appear distorted in shape.
• Baker Grade IV - The breast is hard, and has become quite distorted in shape. Pain/discomfort may be associated with this level of capsule contracture.

• Description of capsular contracture
• Photos of complications
• More info on capsular contracture
• Yet more info on capsular contracture (graphic images)

When implants “bottom out”, this means that the implants have descended too low on the chest, thus making the nipple too high on the breast mount. If bottoming out is apparent shortly after surgery, it is most likely due to over-dissection of the pocket. If it occurs later on, it is usually due to the weight of the implant. The type of implant (saline, silicone, smooth, textured) seems to have no bearing on whether this will occur.

Bottoming out is usually seen in thin patients with very little breast tissue and skin coverage. It is more common with implants placed over the muscle, and is less common with implants placed under the muscle, even less so in cases of complete sub-muscular/sub-fascial placement. Bottoming out is seen when the implants end up too low on the chest wall and the nipples end up positioned too high on the breast mounds, tending to “pop up” out of a bra or bathing suit top. It is the loss of internal implant support where implant placement with partial to no muscle coverage allows slow downward migration of the implants. This is because support of the implant by the skin alone is not always enough to prevent downward migration of the implants. Over-dissection of implant pockets at the time of surgery may cause immediate bottoming out, with the implant effectively being in the wrong position to start, and possible continued migration southwards.

So for those of you considering extra-large implants and hoping to “lower the fold” on your chest wall (even assuming you can find a surgeon who will agree to doing this), this is a very real risk to consider. You might at first think that having your nipples appearing to be higher on the breast mound to be desireable, but the look when taken to this extreme isn’t flattering at all.

• JustBreastImplants.com
• site of Dr Thomas M. DeWire, Sr., MD, FACS

• Breast implant at Wikipedia
• Breast Implants A Historical Timeline
• History of Breast Implants
• Inamed Matrix of Breast Implants
• Mentor's larger breast implants

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