Scientific Forum
The Postoperative Shape of Round and
Teardrop Saline-filled Breast Implants
Robert S. Hamas, MD
Background: Teardrop saline-filled breast implants have been portrayed as having a
more natural shape and appearance than round saline-filled implants. However, there
are no data in the literature supporting this assertion.
Objective: This study was conducted to evaluate the postoperative shape of round
implants and compare it with the shape of teardrop implants.
Methods: With patients upright and with nothing touching the breasts, lateral radiographs were taken to document the in vivo shape of breast implants. A total of 14 round
saline-filled implants in 7 breast augmentation patients were studied. Implants included
both smooth-surface and Siltex textured-surface models. Some implants were placed
submuscularly and others subglandularly. None of the patients had capsular contracture.
For comparison, 12 teardrop saline-filled implants in 6 breast augmentation patients
were studied; all of these patients had BioCell textured-surface implants placed submuscularly, and none had capsular contracture.
Results: Lateral radiographs with patients upright show that round and teardrop
implants have similar teardrop shapes in vivo. Postoperative photographs also show a
similar appearance. Lateral radiographs with patients recumbent show that the teardrop
implant remains teardrop-shaped whereas the round implant settles back evenly.
Conclusions: Although round and teardrop implants exhibit significantly different
shapes on a table, they have similar teardrop shapes in vivo with patients upright.
Because the appearance of the breasts with patients upright is similar for the 2 implant
types, there is no basis for the claim that teardrop implants provide a more natural
appearance. Round implants are actually more “anatomical” because they are teardropshaped with patients upright and settle back evenly with patients recumbent, as do
normal breasts.
T
he choice of implant shape for breast augmentation can be difficult for surgeons
and patients, especially with today’s advertising and marketing programs. No
published study has compared round and teardrop saline-filled implants with
respect to postoperative shape or appearance. Although the implant shapes look different in side view on a table, what are the postoperative shapes with patients upright?
Does the difference in implant shape give one type of implant a more natural looking
result1 or a more anatomically correct profile2 than the other? A study was done to help
surgeons and patients evaluate round and teardrop saline-filled breast implants by
demonstrating the postoperative shapes with patients upright and recumbent. The study
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Dr. Hamas is in private plastic
surgery practice in Dallas, TX.
Presented in part at the 32nd
Annual Meeting of the American
Society for Aesthetic Plastic
Surgery, Dallas, TX, May 16, 1999.
Accepted for publication June 17,
1999.
Reprint requests: Robert S.
Hamas, MD, 8345 Walnut Hill,
Suite 120, Dallas, TX 75231
Copyright © 1999 by The American
Society for Aesthetic Plastic
Surgery, Inc.
190-820X/99/$8.00 + 0
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Table. Characteristics of breast implants studied
Implant
number
Implant shape
Surface type
Manufacturer’s
fill range (cc)
Actual fill (cc)
Months
postoperative
Round
Round
Round
Round
Round
Round
Round
Round
Round
Round
Round
Round
Round*
Round*
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Teardrop
Siltex
Siltex
Siltex
Siltex
Siltex
Siltex
Smooth
Smooth
Smooth
Smooth
Siltex
Siltex
Siltex
Siltex
BioCell
BioCell
BioCell
BioCell
BioCell
BioCell
BioCell
BioCell
BioCell
BioCell
BioCell
BioCell
475-525
475-525
425-475
425-475
375-425
375-425
375-425
375-425
300-325
300-325
225-250
225-250
150-175
150-175
350-370
350-370
300-315
300-315
300-315
300-315
270-285
270-285
270-285
270-285
270-285
270-285
525
525
475
475
435
435
425
425
350
350
225
225
150
150
360
360
310
310
300
300
270
270
270
270
270
250
28
28
47
47
8
8
15
15
14
14
74
74
8
8
15
15
11
11
11
11
26
26
24
24
36
36
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
*Subglandular.
also compared the postoperative appearance of the augmented breasts with patients upright.
The vast majority of breast implants are “round”—a
term that refers to the shape in front view, lying flat on a
table, before implantation. Postoperatively, with patients
upright, it is intuitive but undocumented that round
implants become teardrop shaped in side view because of
the effect of gravity.
Since the mid 1970s, some breast implants have been
“teardrop-shaped”—a term that refers to their shape in
side view, lying flat on a table, before implantation. The
early teardrop implants were generally unpopular because
they did not seem to affect the postoperative breast shape
and could rotate. Recently, a teardrop saline-filled implant
(McGhan Medical Corporation, Santa Barbara, CA) was
introduced that is fully filled so that it retains its teardrop
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shape whether the patient is recumbent or upright. Despite
the fact that a normal breast is not teardrop-shaped when
the patient is recumbent, this new implant has been marketed as “anatomical.”2
In comparing round and teardrop implants, Tebbetts3
opined that all round implants are underfilled and that
the upper pole of any such implant collapses when it is in
the upright position. He also stated that when patients
are upright, round implants have upper-pole shell
collapse if filled to the manufacturer’s recommended fill
volumes or even substantially beyond the manufacturer’s
recommended fill volumes.4
Tebbetts’3 conclusions about round implants came from
sitting patients upright during surgery, looking into the
top of implant capsules, and observing that the implant
had fallen to the bottom of the capsule and had upper
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A
B
Figure 1. A and B, Upright lateral radiographs of the 14 round implants from 7 patients. Implant numbers correspond to those in the Table.
A
B
Figure 2. A and B, Upright lateral radiographs of the 12 teardrop implants from 6 patients. Implant numbers correspond to those in the Table.
The Postoperative Shape of Round and Teardrop
Saline-filled Breast Implants
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the patients had smooth-surface implants (Mentor Style
1600); the other 3 had Siltex textured-surface implants
(Mentor Style 2600). Each implant was in a submuscular
pocket without capsular contracture. The postoperative
period ranged from 8 to 47 months. All implants were
filled at least to the upper limit of the manufacturer’s recommended fill volume.
A
Two additional breast augmentation patients with round
saline-filled implants were added to the study because their
implants were filled only to the lower limit of the manufacturer’s recommended fill volume; both of these patients
had Siltex textured-surface implants (Mentor Style 2600)
without capsular contracture. The implants were submuscular in one patient (74 months postoperative) and subglandular in the other (8 months postoperative).
B
Figure 3. A, Composite of 7 round implant shape tracings from
upright lateral radiographs. B, Composite of 6 teardrop implant shape
tracings from upright lateral radiographs. Note similarity of composites
A and B.
pole collapse. However, the surgical technique of opening
the capsules and looking at the implants was flawed as a
means of evaluating the postoperative shape of round
implants with patients upright. This is because air was let
in when the capsules were opened, which broke the negative hydrostatic pressure gradient between implant and
capsule; as a result, the implants fell to the bottom of the
capsule and had a collapsed upper pole. This is analogous to opening the chest wall and letting air into the
pleural space, thereby breaking the negative hydrostatic
pressure gradient between lung and pleura, and then
observing the collapsed lung. Although the round
implants were in situ, the conditions were not in vivo
because of the air artifact in the capsule. Thus, the upper
pole collapse seen when the capsules were opened is not
valid evidence for Dr. Tebbett’s statement that round
implants are underfilled.
Rather than try to observe the shape of breast implants
during surgery, I developed a noninvasive radiographic
approach to determine in vivo implant shape. With
patients upright or recumbent, and with nothing touching the breasts, lateral radiographs readily show the in
vivo shape of breast implants in side view.
Materials
Five breast augmentation patients with round saline-filled
implants were chosen at random from my practice. Two of
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For comparison, 6 breast augmentation patients with
teardrop saline-filled implants were chosen at random
from the practice of another surgeon. All had BioCell
textured-surface implants (McGhan Style 468). All of
these implants were in the submuscular pocket and without capsular contracture. The postoperative period ranged
from 11 to 36 months. Each implant was filled within the
manufacturer’s recommended range of fill volumes.
Data on the 26 implants studied are listed in the Table.
Methods
For this study, all radiographs were taken on a mammography unit by the same technician through use of a chest
wall view technique with an aluminum/molybdenum filter and manual exposure. Upright lateral radiographs
were taken of all 26 implants. Recumbent lateral radiographs were taken of one round and one teardrop
implant, each filled to the manufacturer’s recommended
minimum fill volume.
For the illustrations in this report, radiographs were
scanned and digitized. In radiograph areas that were
extremely dark, the Adobe Photoshop 5 (Adobe Systems,
Inc., San Jose, CA) software dodge tool was used by an
independent computer graphics artist to lighten the image
so that the implant outline would be more visible. The
outlines were not altered in any way by this software
technique.
To show the similarity in postoperative implant shapes,
composites of round and teardrop implant outlines were
made by the computer graphics artist. One radiograph
was chosen at random from each of the 13 patients,
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A
A
B
Figure 4. Typical upright lateral radiographs show implants with similar teardrop shapes and with folds in shells. A, Round implant with
folds distributed randomly on the surface. B, Teardrop implant with
folds oriented longitudinally on the posterior surface.
and the implant outline was traced onto clear plastic
through use of a spotlight behind the radiograph when
needed. Then the tracings were digitized and the 7
round implant tracings superimposed to make one
composite. The 6 teardrop implant tracings were superimposed to make another composite. To get the best
superimposed fit, each tracing was tilted and/or scaled
up or down to adjust for implant size and magnification
on the radiograph.
Results
All 14 lateral radiographs of round implants with
patients upright showed that they were teardrop-shaped
in side view (Figure 1). This was the finding for all of the
round implants—smooth and Siltex-textured, submuscular and subglandular, 8 to 74 months postoperative,
different sizes, and fill volumes ranging from the manufacturer’s recommended minimum to 25 cc over the recommended maximum. There was no rounded upper
fullness or upper-pole collapse. When these radiographs
were compared with the 12 lateral radiographs of
teardrop implants (Figure 2), it was evident that the
round and the teardrop implants had similar teardrop
shapes. This similarity was clearly demonstrated in the
implant shape composites for round and teardrop
implants (Figure 3).
In all 26 patients, the upright lateral radiographs also
revealed shell folds in a random distribution on the sur-
The Postoperative Shape of Round and Teardrop
Saline-filled Breast Implants
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B
Figure 5. Typical postoperative photographs show similar appearance
of the breasts. A, Round implant. B, Teardrop implant.
face of the round implants and in a vertical orientation
on the posterior surface of the teardrop implants
(Figure 4).
A comparison of postoperative photographs with
patients upright showed that the breasts had a similar
appearance after augmentation with round and teardrop
implants (Figure 5).
Recumbent lateral radiographs demonstrated that the
round and teardrop implant shapes lying flat on the ribs
were similar to the round and teardrop implant shapes
lying flat on a table (Figure 6).
Discussion
This study documents what was intuitive: that round
saline-filled breast implants are teardrop-shaped in side
view with patients upright. Illustrations depicting round
implants as hemispherical in side view with patients
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The absence of upper-pole collapse of round implants
filled within the manufacturer’s recommended range indicates that these implants are adequately filled. This study
shows that the tilt test used by Tebbetts,3 in which a
round implant is tilted on one hand while the lower pole
is supported with the other, does not mimic round
implants in vivo and is therefore not a reliable test for
adequacy of implant fill.
Radiographs showed shell folds on the less fully filled
round implants as well as on the more fully filled
teardrop implants. This finding was surprising because
the purpose of filling teardrop implants more fully, even
though this increases implant firmness, is to avoid shell
folds.3
A
Conclusion
B
Figure 6. A, Recumbent lateral radiograph of round implant number
11 shows how implant settles back evenly with the patient recumbent.
B, Recumbent lateral radiograph of teardrop implant number 25 shows
how implant retains its teardrop shape with the patient recumbent.
upright are incorrect.2 Furthermore, because round and
teardrop saline-filled implants have similar teardrop
shapes with patients upright, there is no basis for the
claim that one provides a better or more natural-looking
breast than the other. In this series of patients, the resulting breast shape with patients upright was similar for the
two types of implants.
With patients recumbent, round implants settle back
evenly like normal breasts, whereas teardrop implants
maintain their teardrop shape. Thus, with respect to the
shape when a patient is upright as well as the shape when
a patient is recumbent, round implants are actually more
“anatomical” than teardrop implants.
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Lateral radiographs of patients upright or recumbent,
with nothing touching the breasts, reveal the true in vivo
shape of breast implants. Although round and teardrop
saline-filled implants exhibit different shapes in side view
on a table, they have similar teardrop shapes with
patients upright and give a similar appearance to the
breasts. Round implants are actually more “anatomical”
because they are teardrop-shaped with patients upright
and settle back evenly with patients recumbent, as do
normal breasts. ■
I thank Barbara A. Marshall, RT(M), for her technical
advice and assistance in obtaining the radiographs, and
computer graphics artist Bryan Beamon for production
of the illustrations.
References
1. Tebbetts JB. Breast augmentation: the biodimensional approach. Texas
Monthly 1999;27:133.
2. Choosing breast augmentation. Santa Barbara: McGhan Medical
Corporation; 1998. p 6-7.
3. Tebbetts JB. What is adequate fill?: implications in breast implant
surgery. Plast Reconstr Surg 1996;97:1451-4.
4. Tebbetts JB. Use of anatomic breast implants: ten essentials. Aesthetic
Surg J 1998;18:377-84.
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