Saline Versus Silicone Breast Implants: Is It Really a Dilemma?
When women consult with me about breast augmentation, they frequently have many questions about what type of implants I prefer. In some cases, patients present with fairly significant biases for or against one type of implant. When I query them about the basis of their preferences, they sometimes quote information that is not quite true or is blatantly mythical. In this article, I will explain the biases I have regarding breast implants, and the science behind my biases, as well as discuss breast implant maintenance issues.
Most of us very clearly remember reading about the “silicone breast implant crisis” in the newspaper in the 1990s. Unfortunately, much of what was published was untrue, and this information created near hysteria in many patients who had silicone implants. What was true was that older generation silicone implants were not as durable as we would have liked, and subsequently, many women developed leakage of silicone gel into their surrounding breast tissue. This occasionally did lead to breast lumps, scar tissue and a need to remove or exchange the implants. What it did not lead to was an increase in auto-immune deficiency or other diseases that some women felt they developed because of their silicone breast implants. In very large-scale studies, women with leaking silicone implants were found not to have any higher rate of any diseases as compared to women that had never had breast implants of any kind.
While the FDA was collecting this data, they briefly took silicone implants off the market. When the data was sorted out and the implants were found to be safe, the FDA allowed redesign of the implants. The goal was to make them more durable. The newly designed implants are what I use now. They are called cohesive gel implants. The shells are thicker and more durable, and the gel inside is now so thick, that even if a hole or tear develops in the shell, the gel cannot ooze or leak out into surrounding tissue.
The vast majority of older generation silicone implants were found to be leaking ten years after placement. This is how the misbelief was started that all silicone implants have to be replaced ten years after placement. While as many as 70 percent of the older silicone implants were leaking by ten years, with the cohesive gel implants I use now, at 10 years post-implantation, only 10 to 13 percent are showing signs of wear. Consequently, older silicone implants probably should be exchanged if they are more than 10 years old, but new generation cohesive gel implants are intact and perfectly fine at that 10-year anniversary.
The FDA originally recommended, but did not mandate, that women have MRIs every two to three years following silicone breast implant placement. At their follow-up meeting in August of this year, they stated that recommendation was probably overkill. I suspect in the near future, high-definition ultrasound will be the screening test of choice to evaluate implant wear. The take-home message is that almost no medically implantable device is permanent. For instance, knee joint replacements also have to be re-replaced, but current day silicone implants are very durable through 10 years. We do not have performance data at longer intervals than that at present as they have only been manufactured for 10 years, but we are actively collecting it.
Many patients worry that silicone may be toxic or foreign to their system and cite this as their reason for preferring saline implants. The shell on both saline and silicone implants is made of silicone elastomer, so both types of implants contain silicone. We have silicone in our toothpaste and baby-bottle nipples are also made of silicone. In general, it is an inert substance and is quite safe.
My bias in favor of silicone implants primarily has to do with my unwavering commitment to creating natural appearing breast augmentation results. Silicone implants simply look and feel more natural than saline implants. While any type of implant can exhibit rippling of the overlying skin, saline implants have a much greater incidence of doing so. Current-day silicone implants also have the lowest rate of developing scar tissue around them, which is called capsular contracture.
In my opinion, there are only two benefits to saline implants over silicone. One is that when a saline implant develops a hole or a tear in the shell, it deflates fairly rapidly and it is easy to tell it is time to replace the implant. Saline implants do not need to be replaced until or unless they deflate. The other is that the size is adjustable during surgery by filling the implant with more or less saline. Some surgeons feel they are able to obtain better symmetry with this option. While silicone implants are not adjustable, I use silicone breast implant sizers in surgery. I temporarily insert them to determine what implant size or variation in size creates the best symmetry. I do not feel that the adjustability of saline implant size makes up for its excessive firmness.
During the “silicone implant crisis,” many women who had silicone implants came to see me in consultation desiring exchange of their silicone implants for saline implants. Their motivation was primarily related to fear induced by the misinformation they read in the lay press. Nevertheless, many did have implant exchanges. Many were subsequently unhappy with their saline implants and cited excessive firmness and rippling as the source of their disenchantment. These same patients returned in droves when silicone implants became available again to switch back to silicone implants. Based on this experience, I would say that patients who have had both types of implants overwhelmingly prefer silicone. Satisfaction with silicone implants is so much higher, that Mentor, the implant manufacturing company whose implants I use, offers incentives for patients to exchange their saline implants to silicone.
Women who are very thin and have exceedingly little breast tissue are poor candidates for saline implants, as rippling and firmness are more pronounced in this group of patients. The FDA has not approved placement of silicone implants in women under the age of 22. They stated that women in this age group may be unable to make a good decision about long-term effects. I personally feel that a well-informed 22-year-old is capable of such a decision, so with a signed waiver, I am willing to offer silicone implants to patients between 19 and 22. The waiver states they are aware of the FDA’s position on this issue, but they have been fully informed about the benefits and risks and desire to proceed.
It is truly a very personal decision as to what type of breast implant a patient desires, and after discussing the pros and cons of each device, I ultimately allow the patient to pick which implant suits them the best. The good news is that implant technology has continued to improve dramatically over my years in practice, and I suspect it will continue to do so.