Wednesday, May 18, 2011

Silicone or Saline... What's better for breast Augmentation?

Silicone or Saline... Which is better for breast augmentation?

Breast augmentation has become the most popular cosmetic plastic surgery procedure over the past few years.
By 2006 approximately 330,000 breast augmentations were performed in the US up approximately by 55% when compared to 2000.
Silicone implants have been utilized since the 1960's and have been evolving ever since.  4 Years after the introduction of the silicone implant, the first inflatable saline implant appeared on the market and was later purchased by Mentor. Since then several generations of both silicone gel and saline implants have appeared on the market for widespread medical use.
The safety of silicone gel implants became the subject of serious speculation during 1992  which lead to a moratorium on their use in the US. Since then, several large scale studies directed at clarifying the role of silicone implants in relation to connective tissue diseases have extended our understanding of these biomaterials and shown no causality between the two.

                                              Courtesy of Mentor and 
                                                              Textured and Smooth Silicone gel implants by Mentor

After 1993 the fourth generation of silicone breast implants was introduced into the marketplace for general use. This generation differs from its predecesors in that it has a multilayered construction and much less "bleed" of silicone when ruptured. An increase in the crosslinkage of the silicone itself creating a "gummy bear" like material that retains it's shape better and is cohesive so as to not spill into adjacent tissues if ruptured it the current concept in comercial designs. Companies like Inamed, Allergan and Mentor, are at the continuosly propelling the development of more sophisticated designs  that are aimed at a natural appearence and consistency.
Fifth Generation Cohesive Gel implants are currently undergoing clinical trials.

Do breast implants cause cancer?
This is a common concern among women seeking Cosmetic procedures such as augmentation, augmentation/mastopexy and breast reconstruction after mastectomy. To date several large scale studies conducted internationally  and in the United States have failed to find a connection between slilicone implants and Breast cancer.
More recently, however attention was focused on the possible association of  silicone breast implants and the development of a rare type of Lymphoma (lymphatic cancer of the breast) known as Anaplastic Large Cell Lymphoma (ALCL). 34 cases were identified world wide in a literature review quoted in the FDA's website, and a total of 60 cases have been reported in association to breast implants. There is ongoing research to elucidate if there is in fact a causal relationship and if so, what is the mechanism. It is important to keep in mind that this number represents a very minuscule percentage of the 5-10 million women who have breast implants worldwide.
Silicone implants                                                                                                      Saline Implants 
Courtesy of                                                                                         Courtesy of     

This decision is based on several factors and should address some important questions during the consult, such as..
-What is the ultimate goal for size and appearence that the patient desires from the procedure; Specific concerns and goals should be discussed with the patient about what the procedure will offer immediately postoperatively in addition, possible changes that may occur in the long run from months to years after the procedure.
-Is the patients skin quality such that it will accommodate a sub glandular implant versus a submuscular implant?

Of the 4 approaches (Incision sites) available for augmentation, which would be the least visible and most desirable in the patients view. And which type of implant can be inserted through which approach?
There are 4 accepted approaches for implant placement;
1-The transumbilical approach (for saline implants only); this technique is less popular because it does not allow direct visualization of the plane of dissection and ultimately where the implant will lay. This limits the ability of     the surgeon to precisely create a pocket that will accommodate the implant.
2-Transaxillary approach (Both saline and small-medium silicone implants)
3-Periareolar in which an incision is made at the edge of the areola (Both Saline and Silicone)
4-Inframammary approach, which is located at the crease under the breast (Both Silicone and saline)

Although silicone implants give increased patient satisfaction over all, if the cumulative evidence in favor of this type of material still leaves room for significant concern in the patients mind, a saline implant may be the best option.

Implant rupture rates
Prior generations of implants had a relatively high rate of rupture ranging from 0-69%. Newer generation implants have a much lower reported rate between 0.5% and  3.5%. One study  quoted a 1% rupture rate in the Inamed 410 type implant. As new generations of implants emerge, the rupture rate will most likely improve, and leakage of cohesive material will facilitate implant exchange due to its mechanical advantage.
Leakage of implants may be diagnosed clinically and also with MRI, CT, Mammography and Ultrasound,in different settings. MRI provides the highest sensitivity.
If there is rupture of the implant, it is recommended to simply remove the implant and exchange it for a new one of the same size in the same surgery if there are no other synchronous morbidities at that time such as infection.

Do silicone or saline implants affect lactation?
See article on breast feeding after breast augmentation

Breast Cancer Screening after augmentation
Mammography remains the standard of care for monitoring the breast for potential breast cancer. A special technique called the Eklund technique consisting of displacement of the implant for appropriate visualization of the breast tissue is recommended. MRI is a valuable adjunct for monitoring the breast for cancer, and in addition is highly sensitive for diagnosing rupture of the implant when present.

 Breast implants before and after

                                                            Implants before and after in an athletic frame
                                                                                   courtesy of

Rafael Magana MD

Stay Tuned....
1. Release FP. FDA Moratorium, FDA, Editor, 1992
2. Sanchez-Guerrero J: Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med 1995; 332(25):1666-1670.
3. Tebbetts JB, Adams WP: Five critical decisions in breast augmentation using five measurements in 5 minutes: the hight five decision support process[reprint in Plast Reconstr Surg 2006; 118(7 Suppl): 35S-45S; PMID: 17099482]. Plast Reconstr Surg 2005; 116(7):2005-2016.
Always consult with your plastic surgeon before undergoing any cosmetic surgery.
4. Accessed on May 20, 4:45pm.
5.Berlin, C. M. Silicone breast implants and breast-feeding. Pediatrics 1994; 94:546-49.
6. Silicone Breast Implants and Breastfeeding, Cheston M. Berlin, Jr. MD, Hershey Medical Center, Hershey, PA, from Breastfeeding Abstracts, February 1996, Volume 15, Number 3, pp. 17-18.

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