Dear JT
   Rippling is one of the most common complications experienced by women undergoing breast
augmentation with saline filled breast implants. From their own studies, the companies which manufacture these devices place your risk of developing ripples (which they refer to as wrinkling),
at between 14% and 20%, with a follow-up period of three to five years. The chance that you will
develop ripples depends mainly on three factors, and I will list these and discuss them separately.

1. Your anatomy: As a general rule, the thinner the layer of tissue is which covers the implant, the
more likely you are to show ripples. Therefore, if you are a B-cup and have an average amount of
body fat, you are less likely to develop ripples than a woman who has an A-cup and so little body fat
that the ribs are easily visible on the side of the chest.

2. Implant type: Saline implants more frequently result in visible rippling than silicone gel filled breast
implants. For this reason, if your Plastic Surgeon thinks that you have a higher than average risk of
developing ripples, it may be suggested that you consider having silicone gel filled breast implants.
In my opinion, both liquid silicone gel and cohesive silicone gel filled breast implants have a lower
risk of developing visible ripples. However, this has to be balanced against other risks which may be
associated with silicone filled implants, and you have to realize that some patients will develop ripples
even when these alternate implants are employed.

3. Implant position. Sometimes it is advantageous to place an implant on top of the muscle, rather
than under the muscle. This is particularly true if one is trying to maximize the "lifting effect" of BA, or
if the patient wishes to avoid the distortion of the breast which may accompany active muscle
contraction (when the implants are under the muscle). In most cases, it is preferable to place saline
implants under the muscle. If saline implants are placed on top of the muscle, ripples may eventually
become visible in the upper-inner aspect of the breast, which can be highly unsightly, especially in a
bathing suit or low-cut dress. If the decision is made by you and your surgeon to place the implants
on top of the muscle, I would recommend cohesive gel implants, to minimize the likelihood of ripples.

   In my experience, most patients with saline implants develop palpable ripples. In other words, the
ripples can be felt along the lower and outer edge of the implant (where the tissue layer is thinnest),
but the ripples can't be seen. A significant number of these patients will also have ripples visible on
the outer aspect of the breast which show only when they bend forward and the breast falls away
from the chest wall, as in when you bend forward to touch your toes. This type of ripple is often of
no concern to the patient, as they can't normally see it without assuming an awkward pose and
looking in the mirror. Only the small minority of patients have ripples visible in a normal standing
posture, and these tend to be the very thin patients with minimal breast tissue pre-BA.

   To summarize, visible ripples are not inevitable with saline implants, but you need to consider all
the factors outlined above and discuss these issues with your surgeon. If you are anatomically at
high risk for ripples, and you think you will be dissatisfied with your result if some develop, then
your surgeon might advise you to avoid saline implants.

Good luck with your decision!
Dr. David Ward. M.D., F.R.C.S.C.
www.drdavidward.com