Most consultations spend their time on size. It is the decision patients arrive with, and it is not the decision that most changes the operation, the recovery or how the result looks in ten years. There are five choices, and they interact.

Filling
Silicone gel or saline
Shape
Round or anatomical (teardrop)
Surface
Smooth or textured
Plane
Over the muscle, under it, or partially under

The plane is the decision that matters most

An implant can sit directly behind the breast tissue, or behind the chest muscle, or in a hybrid position where the upper part is covered by muscle and the lower is not.

Under the muscle gives more soft-tissue cover over the top of the implant, which matters a great deal in a thin patient where the edge would otherwise be visible or palpable. It also generally means a more uncomfortable early recovery, because a muscle has been lifted, and it can produce visible movement of the implant when that muscle contracts.

Over the muscle is usually a gentler recovery and avoids that animation, but relies on the patient having enough of her own tissue to cover the implant convincingly.

Silicone and saline

Modern silicone gel is cohesive — it holds together rather than running if the shell is breached. It is generally described as feeling closer to breast tissue. Its disadvantage is that a rupture can be silent, which is why imaging surveillance is recommended and the recommendation varies by country.

Saline implants are filled after insertion, so they need a smaller incision, and a rupture is obvious immediately because the implant deflates and the saline is absorbed harmlessly. They are more prone to visible rippling, particularly in thin patients.

Things that are true of every implant

  • They are not lifetime devices. Many women will need a further operation at some point, whether for rupture, capsular contracture or a change in preference.
  • Capsular contracture — the scar capsule around the implant tightening — is the most common reason for reoperation.
  • Implants do not lift. A breast that has descended needs a lift, with or without an implant, and using a larger implant to substitute for a lift produces a heavier breast that descends further.
  • Textured implants have been associated with BIA-ALCL, a rare lymphoma of the capsule. Regulatory positions differ by country and this belongs in the consultation.
How do I choose a size?

By what your tissue will carry and how you want to look dressed, not by a cup letter — cup sizing is not standardised between manufacturers. Sizers, and photographs of results in patients with a similar starting point, are worth far more than a number.

Will I be able to breastfeed?

Most women can after augmentation, and the incision site and plane both influence the risk. If this matters to you, say so before the approach is decided rather than afterwards.

Do implants affect mammograms?

They can obscure part of the breast on a standard mammogram. Additional views are used, and you should tell the radiographer you have implants. It is not a reason to avoid screening.

How often should they be checked?

Follow whatever surveillance your country recommends for your implant type. Do not treat "no symptoms" as evidence that nothing has changed, because a silicone rupture frequently has none.