I have been interested in having a breast augmentation but an a little confused regarding the choice between a saline filled or a silicone gel filled implant.

Tori G Coto de Caza, CA

SILICONE GEL BREAST IMPLANTS
PANACEA OR TIME BOMBS?

By Juris Bunkis, M.D., F.A.C.S., Medical Director, Orange County Plastic Surgery Rancho Santa Margarita, CA

Fashion may be fickle but women have been coveting bigger breasts for centuries. More and more women opt for breast augmentation each year. 212,500 breast augmentations were performed in the year 2000 but the number had increased to 291,350 by 2005, a 37% increase, and in spite or our current weak economy, this number just continues to grow! In November of 2006, silicone gel implants were reapproved by the FDA for breast augmentation in the United States and this created a flurry of interest in breast augmentation with gel implants. In review, the first surgical attempts at breast enlargement occurred in the 1890’s using paraffin injections but the long term results were less than satisfactory. By the 1920’s, this technique has been replaced by fat transplants. Surgeons would remove large blocks of fat from the abdominal wall or buttocks and place it into the breasts. The results were satisfactory initially, but shortly thereafter, the fat would begin to absorb, abscesses would form and the patient would be left with a lumpy breast, not much better than the ones enlarged with the paraffin. In the 1950’s, polyvinyl sponges were developed and utilized for breast augmentation. Upon implantation, these would inevitably turn into hard balls within the breasts. In the 1960’s, prostitutes in Japan and the United States began receiving liquid silicone injections to increase bust size, but long term, results were similar to paraffin with lumpy, painful breasts with frequent abscess formation. During my years teaching at the University of California in San Francisco, I had occasion to treat a number of poor ladies with hard, lumpy, infected breasts many years following free silicone injections – the only effective treatment was a double mastectomy and subsequent breast reconstructions. None of these historical procedures produced very satisfactory results and breast enhancement remained an uncommon procedure, rarely performed by reputable physicians. But all this changed with the introduction of silicone gel implants in 1963. These implants consisted of a silicone rubber bag filled with a silicone gel. The consistency was that of normal breast tissue and complications were far fewer than with prior surgical attempts at breast enlargement. By the early 1980’s, breast augmentation was accepted as a main stream procedure and had become one of the most frequently performed aesthetic surgical procedures. In the 1970’s, physicians attempted using saline implants, silicone rubber bags which has been filled with salt water, in an effort to decrease the incidence of capsular contractures, a thickening of the scar around may of the breasts first implanted with gel implants. The popularity of the saline filled implants remained low because these implants did not feel as natural as gel filled implants, and the early saline implants had a very high rupture rate.

Most patients implanted with silicone gel devices during the 60’s and 70’s experienced some hardening of the breasts and other complications but patient satisfaction with the procedure remained high because these implants were far superior to the sponges and other materials used prior to the introduction of the gels. Refinements in implant materials and surgical techniques lead to improving results throughout the 1980’s, and continued popularity of such implants. By the early 1990’s, more than two million women world wide had such implants in place. A Connie Chung television show in 1991 raised doubt regarding safety of breast implants, bringing to light that many patients were now walking around with ruptured breast implants and questioning whether breast implant patients had a higher likelihood of developing autoimmune diseases such as arthritis or lupus. Much publicity ensued and the safety of implants was reviewed by the FDA as well as other regulatory health agencies world wide. Most issued rulings that the safety of silicone breast implants had to be studied further and such implants were removed from the market. And studied they were! Literally hundred of scientific studies were carried out, some retrospective, looking at the history of previously performed cases. Others were prospective, studying patients after new implants were inserted in carefully monitored situations. These prospective studies were set up by the major implant manufacturers in the United States, under the auspices of the FDA, and all data was presented to the FDA. I was chosen to be one of the investigators in these studies and was able to have access to silicone implants during the years that they were not available to non-investigators. After carefully studying all the data from these studies and other studies worldwide, the FDA concluded that silicone implants do not increase the incidence of any other diseases. We now know that all implants, whether gel or saline filled, will rupture eventually but the important thing to know is that with current implants and early detection, there is little likelihood of harm to the patient following a rupture of either saline or gel filled implants.

What has changed to make today’s breast augmentation results superior to those of the 1960’s or 1970’s? The gel that was used in the 1960’s through the 1980’s was a thick, gooey liquid. The gel in implants today is “cohesive”, the consistency of a Gummy Bear – when cut in half, these implants stay in one piece and do not “leak”. Secondly, in a mistaken effort to make the implanted breasts feel softer, manufacturers of silicone gel implants up to the 1980’s utilized paper thin shells. Implanted breasts still formed scar tissue and became firm on occasion, but the shells leaked and ruptured frequently. Today’s implants contain thicker and more durable shells. And finally, surgical techniques have improved greatly since the early days of breast implantation. Incisions now much shorter and more hidden, a variety of different approaches, including entry through the arm pit or nipple area, have been developed and placement of the implants beneath the pectoralis major muscle has been perfected.

One drawback of the gels is that ruptures are difficult to detect. With a saline implant, the water gets absorbed by the scar tissue surrounding the implants and the problem is immediately evident as the breast deflates. With ruptured gel implants, the breasts will look and feel the same and the only way to confirm that a rupture has taken place is with annual mammograms or an MRI. We now know that the presence of a ruptured implant cannot cause any diseases, but why would someone elect a gel if a rupture is more difficult to detect? The answer is quite simple – gel implants are far superior to saline filled bags in feel. Patients with saline implants have a higher likelihood of a firm or unnatural feeling breast. Also, surface ripples and wrinkling, or a palpable implant, are far more likely with saline implants. Many patients who were implanted with saline implants during the last 15 years are now coming in to have their breasts evaluated with the thought of replacing their implants with the new gels. But are gel implant for everyone? Dr. Dennis C. Hammond of Grand Rapids, MI, a recognized expert in the plastic surgery community, recently stated, “There is a whole generation of surgeons out there who trained after silicone implants were removed from the market in 1992 and they have had a satisfactory experience with saline implants. Many of these surgeons will continue to use saline implants”. In my opinion, the proper thing to do at this time is to provide each patient with the pros and cons of all available implants types and to let them participate in the implant choice. But once my patients have had a full consultation, including an opportunity to see or feel both types of implants, most today choose a gel implant for themselves.

If you have any specific questions about cosmetic procedures, your best bet would be to see a qualified plastic surgeon to review your options. Pease feel free to contact our office at 949-888-9700 to set up an appointment with Dr. Bunkis; you may also check out our web site at www.ocps.com to see further examples of similar patients.

Actual patient of Dr. Bunkis 18 year old female, before and after axillary approach, subpectoral breast augmentation.