Aesthetic breast augmentation has recently experienced a significant boom in options available to achieve an ideal outcome. Recent statistics show that 333,392 breast augmentation procedures were performed in 2017, remaining as the number one procedure in aesthetic surgery worldwide.1,2 Evolving prosthetic device technology has now brought an array of implant gels, implant shells, and fill ratios to customize shape, composition/fill, and feel of the augmented breast. The Natrelle Inspira line of breast implants by Allergan Medical is a comprehensive portfolio of implants starting with the Responsive series with the softest gel, the SoftTouch series, and the fully Cohesive series (Fig. 1). Selection of the appropriate implant will depend on the patient’s goals and expectations along with anatomical and soft tissue qualities such as thickness and ptosis.
The consumer seeking breast augmentation has become very savvy and is hungry for knowledge about the implants and specific nuances that can be fine-tuned to achieve their goal. With increasing knowledge and awareness, women understand that they ultimately have a choice with implant selection. This is an important concept because no 2 patients or breasts are identical, with each having their own unique characteristics. In addition, each patient has their own unique look and breast aesthetic outcome they desire. With the vast portfolio of currently available implants, surgeons now have a greater ability to produce tailored and desired outcomes.
SILICONE GEL IMPLANT HISTORY
The evolution of the modern breast implant began as a 2-component prosthetic device manufactured with a less permeable silicone elastomer shell filled with either saline or silicone gel. There have been 5 generations of silicone breast implants. This original shell and gel implant was first developed by Cronin and Gerow3 in 1962. Since that time, there have been numerous advances within this arena.3,4
The first generation of silicone gel implant was created using a silicone elastomer as a 2-piece envelope with a seam along the periphery. This implant was a shaped silicone shell filled with silicone gel and a Dacron patch on the posterior shell to prevent rotation.3
Second-generation implants had a thinner outer shell and a low cohesion silicone gel. This led to greater incidences of shell rupture, and silicone gel bleed leading to high rates of capsular contracture. In addition, double lumen implants with a silicone gel inner lumen enclosed in adjustable saline outer lumen came to market but had a high rate of failure.3
The third and the fourth generations of breast implants represented significant advances in technology and quality of breast implants. They focused on improving the strength and permeability of the shell to reduce silicone bleed from the intact implant and to reduce rupture and gel migration. After the U.S. Food and Drug Administration required restriction of these implants within the market in 1992, the fourth- and fifth-generation implants evolved even further.3,4
The fifth-generation silicone breast implants represent advances in the cohesive nature of the gel and improved gel-to-shell interaction. The fifth-generation cohesive gel also known as “gummy bear” devices represent high-strength, highly cohesive silicone gel with lower rates of capsular contracture and shell rupture with improved outcomes when compared with earlier generations of breast implant devices.3,4
These fifth-generation devices are considered form stable implants. Both the Natrelle Inspira SoftTouch and Cohesive lines are considered fifth-generation implants. The more cohesive the gel, the higher the gel–shell ratio and the increased adherence of the gel to the shell. Together all of these qualities tend to enhance the overall maintenance of shape. The gel–shell fill ratio varies among manufacturers and can produce visual differences in clinical cases.
NATRELLE INSPIRA LINE IMPLANTS
The resultant final breast form following an augmentation is not only dependent on the soft tissue envelope of the breast but also the exact implant characteristics.3 The characteristics that can be selected for the Natrelle Inspira implants include smooth or textured surface, size, fill, and profile. Therefore, each implant can impact the final breast form and thus offers the surgeon the ability to change the ultimate result.
The ideal size and shape of the female breast are inherently subjective and relate to personal and cultural norms. There is a lack of consensus on what surgeons would report as ideal. However, most surgeons agree to certain particularly shared thoughts. Current ideals are tight convex lower pole, sloped or concave upper pole, and nipple at 45:55 distributions (upper pole/lower pole) with a slightly angulated upward appearance.4 These ideals, however, are considerably different across the world. With these different perceived ideals, having a continuum of implant behaviors allows the surgeon to select a particular type of implant to achieve an aesthetic goal.
The Natrelle Inspira implant portfolio offers a valuable set of implants to provide an individualized and unique outcome. In evaluating a patient, it is important to understand that it is not about volume, but more importantly about the distribution of volume. The authors believe that to control the breast, the surgeon must control the distribution of fill within the breast. To control the distribution within the breast, the surgeon must control the fill within the implant. The distribution of the implant fill within the breast pocket far outweighs the volumetric cc/mls.
There is a tremendous value of varying levels cohesivity because it allows numerous possibilities and final aesthetic appearances. Having 3 levels of cohesivity allows patients and surgeons to properly select a device based on tissue-based planning and patient’s goals (Fig. 2).
The Natrelle Inspira Responsive line represents the softest least cohesive gel that provides a natural feel, especially in a soft mobile breast soft tissue envelope. Secondary to the device’s lower level of cohesivity the implants have less upper pole maintenance and higher level of concavity in the upper pole providing a more natural sloped appearance. In addition, the reduced gel–fill ratio allows for a more natural feel but potentially more wrinkling and rippling when compared with the more cohesive lines. Fill ratio may help to eliminate rippling. However, each of the Inspira line implants are under filled and not filled to 100%. Therefore, they will not completely eliminate rippling. The level of cohesively will also help but will not completely eliminate. As a general tenant, the higher the level of cohesiveness and the higher the fill, the less potential of rippling and wrinkling is. Rippling cannot every be “eliminated,” but its likelihood can be reduced with the use of more cohesive devices.
The Natrelle Inspira SoftTouch line represents an increasing level of cohesiveness that is a true blend between the softest Responsive line and the fully Cohesive implant. This implant is rapidly becoming the most popular implant with patients secondary to its feel and behavior. Women seem to desire the feel of the Natrelle Inspira SoftTouch device as the Natrelle Inspira Responsive device is often too soft similar to a fatty breast, and the cohesive implant may be too hard. In addition, patients like the idea of having more upper pole integrity of the implant and lower likelihood of wrinkling and collapse. Therefore, the Natrelle Inspira SoftTouch is the authors go to implant for primary augmentation and primary augmentation mastopexy.
The Natrelle Inspira Cohesive line of implants represents a true cohesive device that resists deformation and has the least incidence of wrinkling and rippling. It has the most upper pole stability and the least likelihood of fold flaw which could potentially lead to rupture. The implant consists of the highest level of silicone crosslinking and gel-to-shell interaction. With the highest level of cohesivity, there is less overall movement of the silicone gel within the shell leading to a possible reduction in the development of fold flaw failure. These devices have been very successful in patients with thin soft tissue envelopes providing a device that will not collapse and will have stable upper pole fill with minimal signs of rippling. The device can be used for very fit patients wanting to avoid animation deformities in the subpectoral position by being placed in the subfascial space. In addition, the devices have great utility with augmentation mastopexy cases where patients are keen on upper pole restoration, and lower profile implants can be used to achieve stable upper pole fill without having exaggerated rounded breasts.
As stated previously, the Natrelle Inspira SoftTouch line and the Natrelle Inspira Cohesive lines are considered form stable implants. There is less deformation over time and thus maintenance of shape. These devices allow the surgeon to control the breast shape and long-term results for patients.
There has always been a large emphasis on surgical planning with breast augmentation surgery. The process involves patient education, informed consent, preoperative planning, a refined surgical technique, and a defined postoperative regimen.2,5
Patient selection is also a critical step in any surgical intervention. This is even more critical for aesthetic breast augmentation.
During the education process, there are several important considerations including implant shape, implant type, filler material, tissue plane, and incision location. Both patient preference and the patient’s distinct tissue qualities dictate and determine the appropriate selections.
A purely objective tissue-based planning system, where the doctor ultimately dictates the selection process of the implant cannot solely exist. Patient preference should be included along with the appropriate tissue-based planning regimen to create a true hybrid selection process.
There has been a paradigm shift in our field of breast augmentation with a more patient-centered evaluation and discussion to identify the best operative plan to achieve and maximize a patient’s aesthetic breast results. Each patient has an ideal look that they are trying to obtain. During a consultation, a rapport must be developed with the patient to understand fundamental aesthetic goals including volume, shape, and feel of the breasts. Detailed physical examination must be performed along with cardinal measurements to provide parameters for tissue-based planning. Identification of location of the breast footprint on the chest wall is critical in discussion. The authors use a few detailed parameters during the discussion process. The ideal breast width is a key measurement that helps define appropriate tissue-based planning. The authors also elicit the patient’s desired upper pole fullness and desired cup size. This hybrid approach allows us to narrow the appropriate implant selection.
Use of three-dimensional simulation in preoperative planning can be very helpful during consultations to help select appropriate shape and size of implants and to demonstrate beneficial effects of mastopexy in the ptotic patient.6 Patients will also try implant sizers on using the Natrelle sizing system. The authors feel that the three-dimensional simulation helps to demonstrate the shape and look. Often patients increase the volume of the implants with simulation and then reduce their volume once they use sizer inserts system. In the authors’ experience, sizing is best determined by trying on the implant sizers.
It is critical during the consultation process to show the patients the variety of implants and how they behave. With every consult, the patients feel, touch, and squeeze the implants. Patients will examine the implants on lateral view and see that the Natrelle Inspira Responsive implants have more upper pole collapse and a higher likelihood of wrinkling and rippling versus the Natrelle Inspira Cohesive implant that is more firm with a more resilient upper pole. The authors’ practice has noted a significant shift using the Natrelle Inspira SoftTouch and Cohesive lines.
The Natrelle Inspira Responsive implants are utilized on individuals who desire a very natural look. These implants will behave like an anatomic implant with a soft upper pole (Fig. 3). However, a majority of patients desire a fuller upper pole. In these circumstances, the authors prefer to use Natrelle Inspira SoftTouch implants (Fig. 4). They behave like a true form stable implant maintaining upper pole fullness over an extended period of time. As mentioned earlier, the authors have also noted a sharp increase in the use of the Natrelle Inspira SoftTouch implants for simultaneous augmentation mastopexy patients who request significant upper pole fullness. Using these devices, the surgeon is able to create a more structured and stable breast that has maintained long-term upper pole volume. The Natrelle Inspira SoftTouch device has become the most commonly used device in the author’s practice.
The Natrelle Inspira Cohesive implant is utilized when the surgeon and patient require further stability and structure (Fig. 5). These cases tend to be in revisionary breast surgery, extremely thin patients, or those who lack breast parenchyma. Natrelle Inspira Cohesive implant is the ideal implant for patients wanting maximal upper pole fullness both in primary breast augmentation and mastopexy augmentation. This device has the least amount of wrinkling and rippling and allows for maximum upper pole fill with all profile devices.
The process of implant selection to achieve upper pole fullness changes with the use of more cohesive round implants. For a given pocket and a given implant, the level of cohesiveness would affect upper pole fullness as demonstrated in the figures. Using some more cohesive device, surgeons can now use a lower profile with a larger base width and obtain upper pole fill and convexity without excessive projection. Simply put this idea of stuffing the breast to obtain upper pole fill is unnecessary and moderate volumes can now be used to get upper pole fill without exaggerating volume by selecting a lower profile cohesive device.
IMPLANT SELECTION ALGORITHM
After a thorough explanation of the implant options, both the patients and the authors determine the exact implant option. Formal discussions are regarding options for augmentation including saline implants, silicone gel breast implants, and autologous fat grafting. The majority of patients in the authors’ practice elect to undergo silicone gel breast augmentation. Selection of implants depends on patients’ desires and the type of surgery being performed. Patients presenting for primary augmentation versus revision augmentation versus augmentation mastopexy will have different issues and goals, thus requiring a unique operative plan and implant to be selected.
In primary augmentation, we have seen a large shift toward patients desiring more upper pole fullness; therefore, our primary implant choice is typically the soft touch implant. It provides appropriate upper pole fullness and softness. In addition, a majority of our patient requires a mastopexy, and the authors believe that a more structural cohesive implant will allow stability of the upper pole over time.
In situations where our patients who want an anatomic look or more collapsed upper pole (“the natural look”), the authors choose the responsive implant. This has become less common in the authors’ practice secondary to patient demand. The more cohesive implant device is reserved for very thin patients or secondary revision surgeries requiring even further stability. In situations where patients prefer the most augmented look and rounded upper pole, the fully cohesive device can be used.
The authors’ preferred approach is an inframammary (IMF) incision with a dual-plane submuscular placement. In cases where patients have selected a subfascial implant placement secondary to minimal ptosis or desire to prevent any animation, the Natrelle Inspira Cohesive devices are utilized to ensure minimal wrinkling and rippling.
Patients are marked in the preoperative holding suite and appropriate preoperative photographs are always taken. A thorough discussion of the plan and confirmation of the selected implant sizes is performed. Patients receive general anesthesia with a secured laryngeal mask airway and are prepped with betadine. Tegaderm dressings (3M, Maplewood, MN) are placed over the nipple areolar complexes. Field blocks are performed with ¼ Marcaine and lidocaine mixed in a half and half fashion, approximately 10 cc per side. IMF incisions are made and electrocautery is used to dissect in a superior oblique trajectory preserving the scarpal IMF sling and avoiding any disruption of the IMF. The pectoralis muscle is identified and the lateral border is delineated. Submuscular dissection is performed and dual-plane release occurs. The dissection is carried in a counter clockwise fashion with the muscle division performed last. Meticulous dissection is performed with a bloodless dissection using prospective hemostasis. Avoidance of any contact to the chest wall when possible to limit postoperative pain is an important strategy. The dissection is performed under monopolar electrocautery. Either with a deaver or lighted retractor and effort is made to enter the pocket only once to avoid contamination and rib trauma.
Following dissection of the pocket betadine solution is used for irrigation. The authors advocate that the no touch technique for implant placement is employed on all breast augmentation cases by utilizing the Keller Funnel 2. This likely lowers potential bacterial contamination, decreases likelihood of capsular contracture, reduces implant trauma, and allows for a smaller incision. Prior studies have indicated a 27-fold decrease in skin contact for all smooth gel implants using the funnel when compared with traditional digital insertion.7
A water tight pocket closure is performed with 2.0 Vicryl interrupted sutures followed by dermal and intracuticular closure with 4.0 monocryl sutures. Triple layer surgical paper tapes are applied the incision lines that are maintained for 4 weeks. The patient is then placed in a soft Coobie bra.
All patients participate in an early recovery postoperative program. Patients start with early arm movement and return to activity as soon as possible. The authors do not believe in postoperative massage and think that the pocket needs to maintain control.
The authors believe that a bloodless limited trauma surgical procedure can limit surgical postoperative pain. The majority of discomfort after breast augmentation may arise from muscle spasms due to immobility and posturing. Limited postoperative narcotic use and the early use of nonsteroidal anti-inflammatory drugs are encouraged. Initial dosages of Toradol 30 mg are given 10 minutes before closure by the anesthesiologists, and can be administered to significantly decrease immediate postoperative pain.
The field of aesthetic breast augmentation is in a golden era with the variety of implant choices available. With all of these options, surgeons and patients can customize their selection to achieve a patient’s personal goal. Multiple variables can impact the outcome of breast augmentation. The 2 most important variables are the patient’s breast characteristics and the implant selected. Utilization of a hybrid implant selection process approach with tissue-based planning and consideration of a patient’s desired outcome is critical to success. With the use of the Narelle Inspira varying levels of cohesive implants, surgeons are now more able to provide a customized approach to achieve improved patient outcomes, high levels of patient satisfaction, and reduced need for revision surgery.
Patients provided written consent for the use of their images.
2. Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg. 2012;130:597e–611e.
3. Cronin TD, Gerow FJ. Augmentation mammoplasty: a new “natural feel” prosthesis.Excerpt Medica International Congress Series. 1963;66:Amsterdam: Elsevier. 41.
4. Maxwell GP, Gabriel A. The evolution of breast implants. Plast Reconstr Surg. 2014;134(1 Suppl):12S–17S.
5. Adams WP Jr. The process of breast augmentation: four sequential steps for optimizing outcomes for patients. Plast Reconstr Surg. 2008;122:1892–1900.
6. Roostaeian J, Adams WP Jr. Three-dimensional imaging for breast augmentation: is this technology providing accurate simulations? Aesthet Surg J. 2014;34:857–875.
Copyright © 2019 by the American Society of Plastic Surgeons
7. Moyer HR, Ghazi B, Saunders N, et al. Contamination in smooth gel breast implant placement: testing a funnel versus digital insertion technique in a cadaver model. Aesthet Surg J. 2012;32:194–199.