Silicone Implants Now as Popular as Saline

In June 2009, I blogged about my surprise that the vast majority of Board Certified Plastic Surgeons still prefer saline to silicone breast implants....

http://www.pickartplasticsurgeryblog.com/2009/06/silicone-breast-implants-still-not-as-popular-as-saline.html

I am a big fan of silicone implants because...

• the newest generation of silicone implants have a safety profile equivalent to saline
• silicone implants definitely feel more natural
• silicone implants exhibit less rippling
• silicone implants usually look more natural
• silicone implants will probably be more durable

It looks like my colleagues are starting to agree.  According to statistics just released by the American Society of Plastic Surgeons, rates of use of saline and silicone implants are roughly equivalent.

• Saline Implants in 2009 - 139,221 pairs
• Silicone Implants in 2009 - 137,915 pairs

However, if you compare the numbers from 2009 to the 2008 data, the numbers are even more compelling.  In this tough economy, obviously there are fewer elective surgeries; the total number of cosmetic surgeries is down in 2009 relative to 2008.  However, interest in silicone continues to rise, while saline use declines.

• Total number of breast augmentations in...
• 2008 - 294,284
• 2009 - 277,136
• Saline Implants
• 2008 - 167,125
• 2009 - 139,221
• Silicone Implants
• 2008 - 127,159
• 2009 - 137,915

I use 10 silicone implants for every 1 saline implant.  I don't mean to disparage saline implants; they remain very good products.  They still have their niche because....

• saline implants are cheaper
• the incisions for saline implant placement are smaller
• the volume of saline implants can be very precisely adjusted

However, silicone is still going to be superior for most women, and I'm glad that my opinions are increasingly shared by other Board Certified Plastic Surgeons.

Few Breast Cancer Victims Opt for Reconstruction

Over the past few decades, plastic surgeons have documented that breast reconstruction improves the emotional well-being of breast cancer victims.  Creating an attractive breast mound after a mastectomy is not only possible, but is beneficial.  Some studies have even demonstrated that the decrease in depression that results from being "made whole" can minimize anti-depressant usage and maximize compliance with adjuvant cancer treatments, such as chemotherapy.  The net effect is increased longevity; breast reconstruction can help breast cancer victims live longer.

Recognizing the value of breast reconstruction, the State of California passed legislation in 1996 mandating insurance coverage for reconstructive surgery.  The federal government followed in 1998.

However, a number of recent analyses suggest that only about 20% of mastectomy patients opt for breast reconstruction.

Researchers from the City of Hope Medical Center, in Duarte, California, recently reported the problem is especially acute in...

• women older than 40
• certain ethnic groups (especially African Americans)
• public insurance (especially MediCal or Medicaid)
• smaller hospitals

Obviously, the results indicate that it is very important to get information out to patients about reconstruction options.  Breast reconstruction is a right!

I would suggest that most breast cancer victims at least consult with a plastic surgeon before cancer surgery.  They need to know that breast reconstruction does not delay cancer treatment, does not minimize the effectiveness of chemotherapy, and does not indicate that they are "vain."  I always want women to really think about their choices.

Breast Implants: Consideration #9: Complications

Are you willing to accept potential complications

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poor scarring, bleeding, infection, malposition, asymmetry, capsular contracture, finite life span of implants, wrong size

Breast Implants: Consideration #8: Adjunctive Procedures? Lift Up? Lipo?

Adjunctive procedures

lipo of the anterior axilla or armpits or water wings

lift up

change shape, such as for constricted breasts

Breast Implants: Consideration #7: Size

not to exceed your body's frame

not to exceed your skin's elasticity

enough to fill the envelope

err on the bigger side

Volumes to go up by a size

32 250

34 300

36 350

38 400

40 ?

Gel is smaller than saline by 8%; go for bigger for gel

 

short, medium, or high profile

Breast Implants: Consideration #6: Position of Implants - Above or Below Muscle

 

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• Subglandular implant:  The prosthesis is placed under the breast tissue but on top of the pectoralis major muscle.
• Subpectoral implant (or submuscular implant):  The prosthesis is placed behind the pectoralis major muscle (which is itself behind the breast gland).

Obviously, Holly, you deserve a customized evaluation, and only then can a Board Certified Plastic Surgeon help you make the best decision.  Nevertheless, there are some general advantages and disadvantages of the two options....

Subglandular Implants

Advantages:

• Technically easier operation for the surgeon
• Can be placed without general anesthesia (without going totally to sleep)
• Larger implants can be accomodated
• Potentially, more cleavage can be created
• No surgery on the muscle; therefore, less discomfort
• No surgery on the muscle; therefore, faster recovery time
• More "lift" effect, so that formal breast up-lift operations can be avoided

Disadvantages

• The "look" tends to be more artificial and less natural
• More rippling
• Greater likelihood of capsular contracture
• More difficult to interpret mammograms

Subpectoral Implants

Advantages

• Usually, a more natural breast appearance
• Less rippling
• Lower risk of capsular contracture
• More successful mammogram readings

Disadvantages

• More difficult operation
• Requires general anesthesia
• Can not always produce as much cleavage as the patient might desire
• More discomfort
• Longer recovery time
• Among women with large pectoralis majors, muscle contraction can distort the implant

Practically speaking, I try to convince most of my patients here in Ventura, California (>90%) to undergo subpectoral placements.  The unusual exceptions...

• Extreme fear of general anesthesia
• Very low pain tolerance
• Looking for a "fake" look
• High performance athletes, whose pectoralis major muscles should not be altered
• Body builders, in whom muscle flexion would distort their breasts during competitions
• Male-to-female transsexuals, whose large XY pectoralis major muscles would not accomodate a subpectoral implant

I like saline implants above the muscle when the patient...

• ...already has a fair amount of breast tissue.
  • Saline implants tend to ripple more than silicone.
  • Hence, those implants need some sort of coverage to camouflage that rippling.
  • That coverage can come from the muscle or from breast tissue.
  • If a woman's breasts are already big, but she would like them even bigger, placing implants on top of the muscle is usually OK.
• ...wants the most natural results when she exercises (nearly) naked(!)
  • The breasts are naturally on top of the muscles.
  • Therefore, if the muscles move, the overlying breasts shouldn't move that much.
  • However, if the implants are beneath the muscles, the breasts might move unnaturally when the muscles contract.
  • Since most women don't exercise naked, this is a minor issue for most patients.
  • Nevertheless, some women do compete in sports in small bikinis, and they are aware of breast distortions with shoulder/chest muscle contractions (such as beach volleyball players, surfers, body builders...see below)
• ...is a body builder.
  • Body builders have very well developed muscles.
  • Contraction of those big muscles would significantly distort the positions of sub-muscular implants.
  • These women do pose nearly naked (in small bikinis) while flexing their muscles.
  • Even though these women do not have a lot of body fat, implants on top of the muscle are generally better.
  • In competitions, the rippling of the implants looks less bad than implant distortion.
• ...has droopy breasts and prefers to avoid formal lift-up procedures
  • Implants themselves provide breast rejuvenation.
  • The muscles tend to mute the rejuvenative/lift-up effects of breast augmentations.
  • Even though many women need mastopexies (lift-up surgeries) at the same time as their augmentations, some patients prefer to avoid the additional scars of mastopexies and accept the limitations of implants on top of the muscles.
• ...is looking for a quicker recovery
  • Most breast implants surgeries do not require a long recovery.
  • However, positioning of the implants below the muscle is more uncomfortable.
  • Staying on top of the muscle is much less painful.

Generally, I use silicone implants when patients choose to have their augmentations on top of the muscle.  Or, better yet, I place implants beneath the muscle in 90% of circumstances...

• to minimize rippling
• to reduce excess scar tissue around the implants (known as capsular contracture)

• Subglandular implant:  The prosthesis is placed under the breast tissue but on top of the pectoralis major muscle.
• Subpectoral implant (or submuscular implant):  The prosthesis is placed behind the pectoralis major muscle (which is itself behind the breast gland).

Obviously, Holly, you deserve a customized evaluation, and only then can a Board Certified Plastic Surgeon help you make the best decision.  Nevertheless, there are some general advantages and disadvantages of the two options....

Subglandular Implants

Advantages:

• Technically easier operation for the surgeon
• Can be placed without general anesthesia (without going totally to sleep)
• Larger implants can be accomodated
• Potentially, more cleavage can be created
• No surgery on the muscle; therefore, less discomfort
• No surgery on the muscle; therefore, faster recovery time
• More "lift" effect, so that formal breast up-lift operations can be avoided

Disadvantages

• The "look" tends to be more artificial and less natural
• More rippling
• Greater likelihood of capsular contracture
• More difficult to interpret mammograms

Subpectoral Implants

Advantages

• Usually, a more natural breast appearance
• Less rippling
• Lower risk of capsular contracture
• More successful mammogram readings

Disadvantages

• More difficult operation
• Requires general anesthesia
• Can not always produce as much cleavage as the patient might desire
• More discomfort
• Longer recovery time
• Among women with large pectoralis majors, muscle contraction can distort the implant

Practically speaking, I try to convince most of my patients here in Ventura, California (>90%) to undergo subpectoral placements.  The unusual exceptions...

• Extreme fear of general anesthesia
• Very low pain tolerance
• Looking for a "fake" look
• High performance athletes, whose pectoralis major muscles should not be altered
• Body builders, in whom muscle flexion would distort their breasts during competitions
• Male-to-female transsexuals, whose large XY pectoralis major muscles would not accomodate a subpectoral implant

Breast Implants: Consideration #5: Location of Incision

There are four commonly used incisions for breast augmentations.

1. Inframammary fold - a gently curved incision in the fold beneath the breast
2. Periareolar - a semicircular incision around the lower half of the areola
3. Transaxillary - a straight incision in an armpit crease
4. Transumbilical - a curved incision in the upper half of the umblicus

According to a recent study published in the Aesthetic Surgery Journal, Board Certified Plastic Surgeons in the USA prefer the inframammary fold and periareolar approaches.  The actual percentages of Board Certified Plastic Surgeons who prefer a particular approach...

1. Inframammary fold - 64%
2. Periareolar - 25%
3. Transaxillary - 8.7%
4. Transumbilical - 0.4%

Why is the inframammary approach most popular?

• Most versatile:  Any type of implant (saline or silicone, round or tear drop, smooth or textured, small or large) can be placed through this incision.  The inframammary approach allows access into either of the available pockets (under the breast or under the breast + muscle).
• Useful for secondary surgery:  Hopefully, you will not need a second (or third) surgery.  However, most implants will not last the lifetime of a women undergoing primary breast augmentations in her 30s.  She should plan on additional procedures.  The inframammary incision can be reused again and again for replacements of implants, corrections of problems, etc.
• Excellent precision:  Because the incision is directly beneath the breast, the surgeon can see what he is doing.  Any bleeding can be immediately stopped.  The pocket domain can be precisely controlled.  There is no need for guesswork.
• Distant from nerves and milk ducts:  Because the inframammary incision is away from nerves and milk ducts, there should (theoretically) be a decreased incidence of nipple numbness and fewer difficulties with subsequent breast feeding.  Moreover, since milk ducts may contain bacteria, remaining distant to bacteria may reduce a patient's risk of infection.
• Good aesthetics:  Inframammary scars tend to heal well; scars rarely hypertrophy (become thick and raised).  Moreover, since an attractive breast has a subtle "hang," the mound should itself obscure the resultant scar.  At the minimum, the inframammary scar should fall within the shadow of the breast.
• Limitations:  Very, very few.
• • Rare patients may have so little natural breast tissue that they don't really have folds; these patients may benefit from another approach.
  • Constricted breasts may be better treated with periareolar incisions.  (Constricted breasts are tight breasts with little tissue other than immediately behind the areolae.)
  • Others may object to the scar, but they must remember that the other scars (periareolar, transaxillary, and transumbilical) may be more advantageous only in the short term.  If those patients need secondary surgery, they are probably going to end up with inframammary incisions anyway.  Then, they have two sets of scars. 

Why is the periareolar incision also frequently used?

• Somewhat versatile:  Many types of implants can be placed through this incision; however, large silicone implants cannot always be placed through small areolae.  Tear-drop-shaped implants may be difficult to maneuver through small areolae too.  Both the subglandular and subpectoral pockets can be created through this incision.
• Particularly useful for constricted/tubular breasts:  The areola can be reduced in size at the same time.
• Can be useful for some secondary surgeries:  Some secondary surgeries can be performed through this approach.  However, on other occasions, the surgeon must convert to an inframammary technique.
• Excellent precision:  Like the inframammary incision, the periareolar approach allows for great control and precision.
• Good aesthetics:  Periareolar scars may be somewhat invisible.  For maximum camouflage, some plastic surgeons advocate tattooing any visible scars with ink similar in color to the patient's natural areolae.
• Limitations:  Some.  But this is still a useful technique.
• • If the patient has small areolae, then the periareolar incisions may not allow for placements of large silicone implants or tear-drop-shaped implants.
  • Some secondary surgeries may still require an inframammary approach.
  • Periareolar incisions may be more likely to damage the nerves that supply nipple sensation.  If erogenous nipple sensitivity is important to the patient, this may not be the best approach.
  • Periareolar incision may be more likely to damage milk ducts.  If the patient might breast feed in the future, then this may not be the best choice.

What are the problems with the transaxillary approach?

• Only somewhat versatile:  Saline implants can be easily placed through the armpit.  However, it is difficult to place even moderate-sized silicone implants through the transaxillary incision.  It would be very difficult (if not impossible) to place tear-drop-shaped implants through this approach.  Both the subglandular and subpectoral pockets can be created through this incision.
• Not useful for most secondary surgeries:  Most of these patients will end up requiring a second set of incisions (probably at the inframammary folds.  Then, they are stuck with four incisions, rather than just two.)
• Reduced precision:  Unless complex endoscopic equipment is used to improve visualization, precision is markedly reduced.
• Usually, good aesthetics:  If the scar heals nicely, then the breast itself has no scars (until the secondary procedures).  However, some of these incisions heal thick.  Then, the patient is stuck with scars that other people will see when she wears routine clothes, such as tank tops.
• Limitations:  Many.  I don't use this technique anymore.
• • While some surgeons claim that they can place small silicone implants through transaxillary incisions, they certainly cannot get medium or large silicone implants through this approach.
  • It would be very difficult to orient tear-drop-shaped implants via the armpits.
  • Secondary surgeries can only very infrequently be performed through the under arms.  Usually, these patients will require inframammary incisions.
  • Without complex endoscopic equipment, visualization is impaired.  Could there be a greater likelihood for bleeding complications and for malpositioned implants?

Why is the transumbilical breast augmentation (TUBA) condemned?

• This is a novelty technique.  Most Board Certified Plastic Surgeons think that it is foolish.
• No versatility regarding implant type:  Only round, saline implants are possible with the TUBA.  It would be impossible to place a silicone implant or a tear-drop-shaped implant with this technique.
• No subpectoral placement:  Only subglandular placement is possible.
• Not at all useful for secondary surgeries, under any circumstances.
• Poor precision:  Most of the patients complain that at least one of the two breasts is "off to the side" or "too close to the middle."
• The scar may be invisible.  However, a secondary procedure would necessitate inframammary or periareolar scars.
• This technique is officially condemned by implant manufacturers.  Use of the TUBA approach invalidates device warranties.

Bottom lines: 

• Like my colleagues around the country, I advocate incisions at the inframammary folds and around the areolae.
• For most patients, the fold will be best, especially since silicone is becoming so much more popular than saline.
• In the unusual patient who either has constricted breasts or poorly defined folds, periareolar incisions may be better.

Breast Implants: Consideration #4: Smooth v. Textured

The shell of a breast implant can be smooth (as shown on the left) or textured (as on the right).

Biophysicists first developed texturing in their attempt to decrease capsular contractures.

• All foreign materials (whether knee replacements, artificial heart valves, or metal rods for stabilizing bones) stimulate inflammation and surrounding scar.
• • The body thinks, "What the hell is this thing?!  I need to protect myself."
  • The resultant inflammation produces the scar.
• Capsular contracture is the specific term for the scar around breast implants.
• While all breast implant patients have some degree of capsule, in 7-9% of patients the scar can be excessive. 
• • The breasts can be too firm;
  • they can be distorted;
  • they can even be painful.
• Below is a patient from Hawaii who presented to my Ventura office with severe capsular contractures.  Ouch.

Textured shells were supposed to decrease the incidence of capsules and to minimize their extent when they did form.  The rationale was that any scar formed around textured implants would be irregularly oriented, and thus less likely to become hard, firm, or distorting.

Most studies, however, have not supported this theory.  Textured implants become hard ("contracted") as often as smooth implants.

Moreover,...

• Textured implants have thicker shells.  Thus, to begin with, textured implants are a bit firmer.
• Textured implants tend to produce more rippling.

Now you know why 92% of Board Certified Plastic Surgeons in the USA use smooth implants rather than textured implants.

So, why do we ever use texturing?

• Rarely, some patients benefit from tear-drop-shaped implants.  The texturing helps to stabilize the implants so that they maintain their orientation.  (Please read my post from 3 days ago.)
• Tissue expanders used in breast reconstruction also have an "anatomic" shape.  Whenever I am treating a mastectomy patient who is interested in a prosthetic breast reconstruction, I always use textured devices to create a pocket for a permanent implant.

(By the way, the Hawaiian patient had a happy ending--albeit after a corrective surgery....)

Breast Implants: Consideration #3: Round v. Tear Drop

Breast implants can be shaped in two common configurations:

• Round (on the left)
• Tear drop (also known as, anatomical) (on the right)

Ideally, a breast itself is shaped like a tear drop...

• Its upper half is full but not protuberant.  The upper profile is straight, not round.
• Its lower half contains the bulk of the breast volume, but is not droopy.  Its profile is round but tight.
• The nipple should point parallel to the floor.  It is located at the peak of the fullness.

If the ideal breast is shaped like a tear drop, why do 96% of Board Certified Plastic Surgeons (including me) prefer round implants?

Is it that we and our patients have grown to prefer Pamela Anderson's "Baywatch breasts," which are...

• round, both in the upper and in the lower halves.
• look more like cantaloupes than tear drops.

I should hope NOT!

We prefer round implants (in the vast majority of patients) because they tend to augment the upper pole proportionately more.  The upper breast is what deflates after pregnancies, breast feeding, and menopause.  Check out Kate Winslet, who has had a couple of kids, and who acted nude in The Reader...

Not that I am pushing breast implants on Ms. Winslet, but using a non-anatomically-shaped implant would restore youthful contours more effectively.

There are at least four other major problems with shaped implants:

1. Bigger incisions:  Placing a tear-drop-shaped implant obviously requires that the upper, less protuberant part is on top, and the lower, fuller half is at the bottom.  To ensure this proper orientation, a surgeon needs a bigger incision.  Mini incisions (just 3-4 centimeters) are usually not possible; 6 cm is more typical.
2. Possibility of rotation:  If a round implant rotates around, so what?  It's round.  If a shaped implant rotates, trouble.  The protuberant part might not be at the bottom of the breast.  The resultant breast could look bizarre.  But you're thinking, "If my surgeon is good, this won't happen."  Well, that's usually true, but no guarantee.  Rotation can happen to even the most compliant patient with the best surgeon.
3. Shaped implants are always textured:  Because of the risk of rotation, the manufacturers have textured the implants, so that the tissue sticks to the implants better.  Thus, texturing does minimize rotation.  Unfortunately, texturing leads to more rippling relative to smooth surfaces.  (I will discuss the smooth v. texture issue in a few days.)
4. Shaped silicone implants are not available in the USA:  Currently, the FDA has approved tear-drop-shaped saline implants, as well as round saline and round silicone.  Tear-drop silicone implants are not available.  If you agree that silicone are superior in most cases (as I did a few days ago), then you must use round.

Breast Implants: Consideration #2: Silicone v. Saline

Breast implants are composed of...

• a shell (made from a silicone elastomer)
• filled with either...
• • saline or
  • silicone gel

Saline literally means salt water.  It is sterile water with physiological amounts of sodium and chloride.  Saline is what's in most hospital IVs.  If a saline implant were to rupture, the woman's body would absorb the saline--just as if she had been given a bolus of IV fluid.  There is 100% safety.

Silicone is a complex polymer with varying degrees of cohesiveness.  Old silicone filler was minimally cohesive; it had the consistency of molasses.  In contrast, the newest silicone fillers are more like gummy bears.  The contained silicone is a liquid but is very cohesive.  Even if the shell were to rupture, the filler would not "spill" inside a woman's body.  It is so viscous that even a split silicone implant retains its general shape...

 

Nowadays, I generally prefer silicone; however, I use both products.  Certainly, there are advantages and disadvantages to the each of the two filler materials.

Proponents of saline implants will argue...

• Saline implants are cheaper:  The two American implant manufacturer's sell saline implants for about $500 a piece.
• • Silicone is $900 per implant.  
• Saline implants are adjustable:  Saline implants can be filled to a range of volumes in the operating room.  Fine adjustments are, therefore, possible.
• • For example, a particular implant could be filled between 300 and 350 cc.
  • Since many woman have one breast which is slightly larger than the other,
  • the implant for the larger breast could filled less--to just 325 cc,
  • while the implant for the smaller breast could be filled more--to 350 cc.
  • Optimal symmetry is thus obtained.
  • Customized adjustments in sizing may be important to those patients who are particularly concerned about their preoperative asymmetry.
  • On the other hand, silicone implants are sealed at the factory.  There is no way to make fine adjustments to any individual implant.
• I can use a smaller incision for a saline implant:  Incisions for saline implants are generally smaller than for silicone implants.
• • Saline implants do not come pre-filled.  On the contrary, they arrive without any fillers.  They are just shells.
  • These shells can be rolled up like cigars and placed through very tiny incisions (each perhaps only 3 cm in length).
  • The shell can then be filled (via sterile IV tubing) after it is already in position beneath the patient's breasts.
  • Since silicone implants are pre-filled at the factory, the incision must be large enough to accommodate the full volume of the implant.  Incisions for all but the smallest silicone implants must then be 4-6 cm in length.
• Peace of mind:  Some patients don't believe that silicone implants (even the newest versions) are safe.  (More on this hysteria later.)  At least with saline, there is no concern for safety.

Proponents of silicone implants will argue...

• Silicone implants have a more natural feel:  Unquestionably, silicone implants feel more like natural breasts.
• • Do a "squeeze test" at your plastic surgeon's office.
  • Saline implants feel like water balloons (which, of course, is what they are). 
• Silicone implants exhibit less rippling:  Have you ever been bothered by the sight of rippling Hollywood breasts?  These women probably underwent saline breast augmentations, like this patient....

• Silicone tends to ripple less than saline.  If you are thin, and if the above picture bothers you, strongly consider silicone.
• There are other ways to minimize rippling in thin patients (such as placing implants beneath the chest wall muscles).
• Silicone implants (probably) produce a more natural appearance:  Most patients do agree that silicone implants look more natural,
• • especially, if they are thin, and if they are small-chested to begin with.
  • Undoubtedly, silicone implants look better when bouncing.  After you do the squeeze test at your plastic surgeon's office, do the "jiggle test."  Silicone implants sway like real breasts.  Saline implants move like water balloons.
• I bet that silicone implants are more durable:  While long-term data on durability are not available, I suspect that silicone implants will last longer than saline.
• • The fill valve on a saline implant is a point of potential failure.
  • There is no "fill valve" on a silicone implant.  It was pre-filled at the factory.