Round saline implants remain the most popular choice for breast augmentation, with 86% of women who undergo augmentation receiving round rather than shaped implants. The advantages of round implants include the creation of a “teardrop” profile in the upright position that rounds out in the supine position, mimicking the behavior of a natural breast ; ease of placement through a variety of approaches; and the choice of a smooth or textured surface. However, an important limitation of the standard profile round implants is that the implant size desired by the patient may not have a diameter that corresponds to the base diameter of the breast. If the implant diameter exceeds the base width of the breast, the implant may be circumferentially constricted, resulting in accentuation of rippling ( Figure 1). Such rippling can be especially conspicuous in the thin patient with little breast tissue because of the easier palpability and greater visibility of the implant. These are often the very patients who desire an implant with a relatively larger volume for their respective size.

The effect of circumferential constriction around a saline implant is demonstrated with a tape measure.

Constricted implants may also be more subject to crease folding, possibly contributing secondarily to higher deflation rates. Attempts to expand the implant pocket to accommodate the larger implant may result in overdissection, which in turn can contribute to symmastia on the medial aspect and to trauma to sensory nerves as they course into the breast laterally. Avoidance of overly wide breast implants minimizes tissue trauma from pocket dissection beyond the breast base. It seems reasonable to conclude that the augmented breast with an implant whose diameter comfortably coincides with the anatomical base diameter is theoretically at lower risk for both aesthetic and physical compromise.

The high-profile saline implants introduced in 2002 by Mentor (style 3000; Mentor Corp., Santa Barbara, CA) and Inamed (McGhan style 68HP; Inamed Corp., Santa Barbara, CA) provide a useful option for breast augmentation. With the choice of different profiles in terms of diameter-to-volume ratios, the patient and surgeon can choose the desired implant volume first and then select the implant profile that best matches the patient’s breast base diameter (a low-profile implant is also available).

High-profile implants may also be beneficial in cases of periareolar mastopexy. The geometry of the periareolar mastopexy may result in central flattening of the breast. The greater projection afforded by the high-profile design helps counteract this tendency.

Measurements and implant selection

The external breast base diameter was measured with the use of calipers. Other important dimensions that were measured included the distance from the areolar margin to the inframammary fold and the distance from the nipple to the sternal notch. The aesthetic goal is to center the implant behind the nipple-areolar complex. A simple pinch test will yield an indication of the thickness of the soft tissue envelope. The ideal implant diameter is the external breast diameter minus the soft tissue thickness. Because some degree of periprosthetic soft tissue thinning is to be expected, the surgeon has a reasonable degree of flexibility in determining the implant dimensions, as long as the base diameter of the implant does not exceed that of the breast. An implant with an excessively narrow base will result in an undesirable space between the breasts and unnatural “cleavage.” My preference is to have the patient select the implant size before surgery through the use of trial implants placed in a bra of the desired cup size. Although this process does not translate perfectly into postoperative results, if the patient is adequately informed about the limitations of the process, a good selection can be made. It must be noted that implants tend to appear smaller than expected after implantation. The type of implant is not important in size selection as long as it will conform to the bra because it is used only to determine the desired volume. Once the size is chosen, the implant with the best match to breast base diameter is determined. The typical indication for the use of high-profile implants is a patient with a narrow chest who wants relatively large implants.

The high-profile implants from Mentor and Inamed differ in the ratio of breast base diameter to projection. Calculations from catalog data show that the Mentor style 3000 implants have a ratio of approximately 2.0 to 2.1 at the midrange of fill volumes, compared with 2.1 to 2.2 at midrange for the McGhan style 68HP from Inamed. The Mentor product provides a greater volume at a given breast base diameter but also yields a correspondingly sharper angle of transition from the chest wall to the breast. High-profile implants may not settle into a teardrop profile in the upright position as well as standard profile round implants (Figure 2).

Oblique and lateral views show the different profiles of standard and high-profile implants. A-C, Preoperative views of a 21-year-old woman. D-F, Postoperative views 6 weeks after augmentation with subpectoral McGhan style 68 (standard, round) implants, 330 cc filled to 350 cc. G-I, Preoperative views of a 27-year-old woman. J-L, Postoperative views 6 weeks after augmentation with subpectoral McGhan style 68HP (high-profile) implants, subpectoral, 320 cc filled to 330 cc. Note that this patient’s chest is narrower than that of the patient depicted in parts A-F, whose chest wall is wider and flatter.

Surgical technique

Preoperative markings were made to facilitate pocket dissection corresponding to the diameter of the implants. Correct positioning of the implants was important in centering the implant behind the nipple-areolar complex. Subpectoral placement may have particular advantages in helping create a more natural transition and compensating for the steeper profile. A closed fill system was always used.

Results

Under the criteria outlined above, 67 of a total of 164 saline breast augmentation patients were selected to receive high-profile implants over a 14-month period. The tendency toward rippling appeared to be diminished, although this parameter is difficult to quantify. Representative results of primary augmentation are shown in Figure 2; results of augmentation with periareolar mastopexy are depicted in Figure 3.