"Screening decisions are complex, and relevant information is lacking. Although the detection of silent silicone implant ruptures may prove to be prudent, there is no conclusive evidence at this time to show that using magnetic resonance imaging screening of asymptomatic women leads to a reduction in patient morbidity. Furthermore, based on existing data, it is unclear whether the potential benefits of screening magnetic resonance imaging tests outweigh the risks and potential costs for the patient."
When choosing breast implants, our Denver plastic surgeons understand that the difference between silicone and saline is significant. This decision will impact both the day-to-day behavior of the augmented breast and the type and frequency of the maintenance of that implant down the road. Unfortunately, there is a great deal of misinformation, hype, and fallacy surrounding silicone, which only makes the decision more difficult. The recent approval of some highly cohesive, form-stable "gummy" implants has given patients more options, but also a more challenging decision to make. Separating fact from fiction, however, can make things much more clear.
Both saline and silicone implants have a shell made from a silicone elastomer, essentially a silicone plastic. The shells for silicone implants are a bit softer than those used to make saline implants. Saline implants are packaged filled with air, and are deflated, inserted, and filled with sterile saline once implanted into the breast. Silicone implants are filled and sealed by the manufacturers and are simply inserted as-is.
Saline implants are currently FDA-approved for breast augmentation in women over the age of 18 and for breast reconstruction in women of any age. Both types of silicone implants implants are approved for augmentation in women over the age of 22, and for reconstruction at any age.
There are significant differences between the three types of breast implants with regards to their behavior within the breast. Silicone implants are inherently more natural feeling, and have a tissue-like consistency that saline implants lack. Silicone implants are also less likely to ripple, either palpably or visibly. These behavioral differences, however, can vary tremendously depending on the characteristics of the patient in whom the implants are placed. In a woman with more tissue, whether it is fat or breast gland, the implants will have more camouflage and the differences between saline and silicone would be more muted. Indeed, in some cases there is sufficient soft tissue that saline implants are virtually undetectable. At the other end of the spectrum would be the thin, small-breasted woman, especially if she's had children, as this tends to decrease the ability of the breasts to hide the nature of the implants used. In short, the more significantly the characteristics of the implant will be noticeable, the better silicone will feel and look relative to saline.
Saline may not look or feel as natural as silicone in many patients, but it does come with a number of different advantages. Saline implants cost less than silicone, and this cost savings is passed on to the patient. The main advantage of saline, however, is the ease of detection of an implant deflation. All implants have a finite lifespan, typically in the range of 15 to 25 years. When a saline implant fails in most cases it goes flat fairly quickly and the body simply resorbs the liquid harmlessly. Replacing a deflated saline implant is usually a straightforward procedure that is easier, less expensive, and less painful than the original breast augmentation. Because saline implants are so easy to replace after they fail, there is no reason to electively change them simply for the sake of replacing them. They are a get-it-and-forget-it implant, and can be dealt with when the need arises.
Silicone implants, on the other hand, are more challenging to follow clinically with regards to their integrity. Many patients with ruptured implants have few or no symptoms in the breast, a scenario known as a "silent rupture". Physical exam by a plastic surgeon in these patients is less than 35% likely to diagnose a rupture when it is present. In a large portion of patients, however, the silicone irritates the surrounding tissues and leads to the deposition of additional scar tissue. This scar tissue leads to a capsular contracture and results in a firm, distorted, and/or painful breast. The condition is surgically correctable, but requires a procedure more traumatic than the original surgery, with recovery and risk proportionate to the level of trauma the surgery causes. Because of this clinical uncertainty of silent ruptures, and increased surgical effort required by a symptomatic rupture, patients who choose silicone implants should consider a more proactive course when it comes to implant screening and elective exchanges.
It is important to note that there is strong data showing that silicone implants, ruptured or intact, are not associated with an increased risk of connective tissue disorders or autoimmune diseases. Quite simply, silicone will not make you systemically ill, but it may adversely affect local tissues.
As a condition of the 2006 approval of silicone implants for cosmetic purposes, the FDA recommends MRI's to assess the integrity of silicone implants and diagnose silent ruptures. Per these recommendations, patients should undergo elective MRI's every other year starting in the third year after surgery. These recommendations have been met with skepticism in the medical industry. Indeed, a recent article on the topic by Colleen McCarthy, M.D. in the journal Plastic and Reconstructive Surgery concluded
There may be some benefit to electively changing silicone breast implants in Denver, Colorado, and many patients choose to exchange their implants for new ones 15 or 20 years after their original surgery. In the absence of a rupture, such a surgery is straightforward and rewards the patient with peace of mind and the latest in implant technology.
A summary of the silicone and saline benefits/drawbacks looks something like this:
- Less expensive
- Detection of leaks easy
- No local complications from rupture
- No need for elective exchanges
- Less natural feeling
- Greater chance of visible rippling
- Very natural feeling
- Less chance of visible rippling
- Implants are more expensive
- Rupture can be difficult to detect
- Ruptured implants can lead to local complication
- The FDA recommends additional screening for detection of rupture
Confounding the discussion of silicone and saline is the fact that there are several different types of silicone implants, including the newly approved "gummies". A clear explanation of the current state of implant technology and availability is tedious but warranted if it can help clear up some uncertainty.
Standard silicone implants currently FDA-approved for cosmetic and reconstructive use that are offered by both Mentor and Inamed, the two largest implant manufacturers, are considered fourth-generation implants. The gel is a thick, cohesive liquid. If these implants rupture they will leak, although the gel tends to stay together somewhat. These are not highly cohesive, form-stable, or "gummy" implants. Referring to them as such is misleading, as it implies that the implants will not leak if the shell fails. This is simply not the case.
There are implants that contain a silicone that is essentially solid, and these implants do have a much lower incidence of rupture than standard implants. These "gummy" or form-stable implants are considered fifth-generation, and are produced by both of the large implant manufacturers: the Mentor CPG and the Inamed style 410. The Inamed 410 was recently approved, and Mentor expects CPG approval shortly. These implants are very popular in Europe and Australia, where they have been approved for quite some time, but it remains to be seen if U.S. patients and surgeons will embrace them as warmly now that they are approved.
Form stable implants have some advantages over standard silicone. They will likely last longer before they have to be replaced, may maintain their position longer, and appear to be more resistant to capsular contracture than standard silicone implants. These implants are best used in a particular subset of patients. The ideal candidate has a relatively small, snug breast envelope and desires a moderately sized, natural looking breast. There are potential downsides to the "gummies", however. First and foremost, they require a significantly higher degree of precision on the surgeon's part when they are place. Unlike a standard round, smooth implant, shaped implants must be inserted into a surgical pocket with a snug "hand-in-glove" fit or they can rotate or migrate, requiring revisionary surgery. (This had an incidence of approximately 3% in clinical trials.) The 410 implants are more expensive than standard silicone, and require a larger incision for placement because they are less flexible and can fracture if over-stressed.
There are other decisions to be made in choosing implants besides the makeup of the implant. Standard implants may be smooth or textured, and, again, arguments can be made for each. (All shaped implants are textured.) Smooth implants are significantly more popular. They tend to ripple less, and may move more naturally within the breast. There is less likelihood of asymmetry, as textured implants may or may not be fixed within the pocket while smooth implants never adhere to the surrounding tissues. On the other hand, textured implants have been shown to reduce the risk of capsular contracture when placed above the muscle, though no protective effect exists when used subpectorally. Textured implants may hold their position better over time due to adherence to the breast tissues.
Once the type of implant is selected, the size must be chosen. There is wide variability in patient size and shape before surgery, and not everyone wants the same postoperative breast size. Two techniques can be used to help educate patients with regards to simulating the appearance of different implants on them. In the first, sizers can be placed in a bra worn by the patient. The effect slightly overestimates the resulting size, but is a good illustration nonetheless. A more precise simulation can be achieved by utilizing state-of-the-art 3-D imaging. The Vectra XD is the newest in a line of imaging devices that capture an image of the patient's breasts and then alter the image to show a "postoperative" view with various implants, including the new cohesive implants. It has been proven to be highly accurate in simulating actual results and can significantly reduce the incidence of reoperation for a size change.
Obviously, implant choice is a complex decision-making process. Consultation with an expert in breast augmentation is the only way to make sure that your individual anatomy, expectations, and desires can be evaluated.
The Center for Cosmetic Surgery has two offices conveniently located in the Denver metropolitan area. One is located just outside of Denver in lovely Golden, Colorado immediately off 6th Ave West and the other is located downtown in Cherry Creek, Denver. Please schedule a personal consultation to learn what plastic surgery can do for you. Simply call (720) 279-1926 or request your consultationconsultation online.
There are several important considerations to learn about when contemplating breast augmentation surgery.
- What type of Implant is right for me?
- How do I choose my implant size?
- How do I best determine what implant profile and shape is best for me?
- How do I decide between silicone gel and saline implant materials?
- Which incision option is best for me?
- Should my implants be placed behind or in front of the pectoralis muscle?
- Do I need a breast lift? What is the purpose of implants versus a lift?
- How should I prepare for my Breast Augmentation surgery?
- What should I expect after my Breast Augmentation surgery?
Why Choose Us for Breast Augmentation
The best thing a breast augmentation patient can do to ensure she gets great results is to choose a top-of-the-line surgeon. All 3 of our surgeons specialize in cosmetic breast surgery and have been recognized by their peers as leaders in the field. We invite you to get to know us and see what sets us apart.