- Instead of silicone or saline implants, breast augmentation patients can now choose to have their own fat transferred to their breasts.
- While some surgeons claim that fat grafting provides more natural results, there are also major drawbacks and limitations to this technique.
- Not all experts agree that teardrop-shaped implants provide more natural looking — or feeling — results than traditional round implants.
We recently spoke with five board-certified plastic surgeons to find out which option provides the most natural breast augmentation results. To our surprise, their answers varied widely.
Choosing the right type of implant and procedure depends on a large number of factors — here’s what you need to know before going under the knife.
Classic, round implants: silicone or saline?
Silicone and saline of implants have been used in innumerable breast augmentation procedures over the years. Some might be inclined to see these implants as dated, but they are time tested classics still regularly in use today.
What will likely surprise you however, is that the experts still can’t quite decide which option offers the best results.
“I think that silicone implants look and feel more realistic,” says Dr. Jon Kurkjian, a board-certified plastic surgeon in Fort Worth.
New York City plastic surgeon Dr. Melissa Ann Doft is of the same opinion. “Almost all of my patients have silicone implants,” she says. “I think they feel much better than saline. They’re softer, have a different consistency, and aren’t as heavy.”
Beverly Hills plastic surgeon Dr. Richard Ellenbogen disagrees. While he would not use saline implants for physically active women, he’s generally in favor of their use. “I like saline implants because they have more bounce,” says Ellenbogen. “When you lay down they go flat, you can put them into a small incision, and they’re adjustable.”
“Almost all of my patients have silicone implants.”
– Dr. Melissa Ann Doft
With the majority of the doctors we spoke with being silicone implant supporters, it might be easy to disregard saline implants altogether. However, the option does exist for a reason. Saline has certain benefits that silicone can’t offer.
Dr. Adam Rubenstein, a board-certified plastic surgeon based in Aventura, FL, prefers silicon implants, but he does defends saline. “Some patients aren’t comfortable using silicone, based on the old FDA restrictions that have been lifted and are no longer relevant,” he says.
Doft is squarely in the silicone camp, but she does see some value in saline implants for some patients.
“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,” says Doft. “Also when price is a concern, saline costs half as much as silicone.”
Certain patients may also see better results from saline implants.
“An 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,” says Rubenstein. “Saline is better when you’re trying to look ‘done,’ so to speak, and are trying to have a firmer, rounder upper pole.”
For those with naturally larger breasts, the question of which option offers the most realistic results is not quite as relevant.
“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,” says Kurkjian. “In other words, if you’re going to feel the implant through the skin, silicone is preferred.”
Fat grafting: a truly natural breast enhancement procedure?
Fat grafting, also called a fat transfer breast augmentation, seeks to address two issues at once. By removing some fat from troubled areas using liposuction, a surgeon can then inject a patient’s own fat into their breast. This makes fat grafting both a mild form of body contouring and a breast augmentation procedure.
One of the biggest advantages of fat grafting is that it provides natural results.
“Fat grafting is probably the most natural breast augmentation method,” says Kurkjian. “Because it’s your own fat, you don’t have to worry about implant failure or exchange.”
While Bellevue, WA plastic surgeon Dr. George Marosan agrees that the results are natural, he also sees limitations to this technique. “Normally, you can’t increase more than one cup size with one fat transfer procedure,” says Marosan.
Kurkjian points out that this limitation is surmountable through a combination of procedures. “Breast implants are required to gain more than one cup size,” he says. “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.”
Longevity and potential complications
For his part, Ellenbogen is not a fan of fat transfer breast augmentation. His first concern is over the longevity of fat grafting, and the long-term impact the procedure may have on a woman’s body.
“I don’t find fat grafting as good as implants,” Ellenbogen states. “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.”
While he does point out that fat grafting is good for breast reconstruction, Ellenbogen explains that fat can have serious long term consequences.
“It will decrease in volume, form cysts, result in retractions of the skin, and grafted fat gains weight when you gain weight,” says Ellenbogen. “Personally, I prefer implants and accept their shortcomings. I think implants are the gold standard, and fat grafting comes in second place. Also, transferred fat doesn’t always feel quite right — it has a rougher character.”
Another factor to consider is that while fat is natural, this very characteristic brings its own set of disadvantages. Unlike synthetics, natural substances die. “Fat has the potential for necrosis, and can form hard nodules,” says Rubenstein.
“Transferred fat doesn’t always feel quite right.”
Dr. Richard Ellenbogen
According to Doft, this feature of natural fat leads to a loss in volume.
“Published studies show that 30 to 50% of the fat will survive, but you don’t really know, so most doctors will overfill or fill until it looks perfect,” she says. “Often you need multiple surgeries, which is something to consider with fat grafting.”
This fat can also be a health concern.
“If you inject fat and the fat dies, it can interfere with the ability to monitor breast cancer, which is diagnosed in one in eight 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,” says Kurkjian.
Apples and oranges
While some more firmly believe in the merits of one option or the other, Doft and Rubenstein are more tepid in their endorsement of one over the other.
“They’re so different that you can’t really compare them,” says Doft. “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.
Rubenstein adds that both procedures offer their own advantages.
“It depends on the tissue the patient has to begin with, and what the patient is trying to achieve. There are things you can do with fat grafting that you can’t do with implants, and vice versa,” says Rubenstein. “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.”
Marosan agrees that a patient’s body and goals need to be carefully considered before selecting any option.
“Achieving a natural look with a fat transfer procedure or implants comes from choosing the appropriate size based on the patient’s measurements, tissue thickness, chest wall symmetry, and breast symmetry,” he says.
Gummy bear implants: a more natural breast shape?
Modern breast implants often come in more molded shapes than traditional round implants. Some see these new implants as a “best of both worlds” solution, as implants can offer more robust results than fat grafting, and these shapes appear to offer more natural-looking results than traditional implants.
The most popular of these molded implants is the “gummy bear” implant.
“The gummy bear implant is a specific kind of silicone implant, which is really a cohesive gel-shaped device,” says Kurkjian. “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.”
Still not convinced
While newer products tend to get a lot of media attention, Marosan isn’t convinced that these implants beat out the classics.
“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,” he says.
Marosan adds that traditional implants may be more realistic than newer gummy bear implants. “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,” Marosan adds.
However, he does not believe that overall the difference between these types of implants is particularly noticeable. “At a plastic surgery conference panel discussion, surgeons couldn’t tell the difference visually between gummy bear and round silicone implants. 80% of the time people guessing got it wrong.”
Round is better
Like Marosan, Doft prefers the traditional round implants. “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,” she says.
Though he sees some use for shaped implants, Rubenstein prefers traditional round implants as well.
“Shaped implants are very good for reconstructive purposes and, on occasion, are good for cosmetic applications depending on the patient’s breast, but I personally prefer round implants for cosmetic use in general,” says Rubenstein. “Silicone doesn’t stay round — it flows and becomes teardrop-shaped when you place it in the breast.”
Although gummy bear implants are often touted as a particularly good option for mastectomy patients, Doft says that even this group has encountered issues.
“Anecdotally, in the study to get the gummy bear implant approved, some mastectomy patients had them removed because they felt they were too hard,” says Doft.
So, what does Doft recommend? “I often use Sientra implants,” says Doft. “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.”
The bottom line: which technique is best?
The experts that we spoke with generally agree that the best option is the dependable classic: silicone implants.
While fat grafting can offer natural breast augmentations results, a number of caveats hold it back from being the go-to choice for many patients. A single graft may not be sufficient to produce significant augmentation. Furthermore, results are less predictable than those that can be attained through traditional breast enhancement techniques.
That said, if you are looking for modest gains or to combine your fat graft with silicone implants, the procedure might be exactly what you are looking for.
In the end, choosing one procedure over another should be an informed decision based on what each option offers and your individual aesthetic goals.
» Still have questions about breast enhancement procedures? Connect with our Medical Review Team.