Dr. Linder's Blog
During consultation, questions often arise as to which implants will be best for the patient, silicone vs. saline. Although both implants are still available, FDA has still restricted the use of silicone gel implants to women who meet specific criteria.
In the United States, both Mentor and Inamed provide FDA approved silicone gel implants for women who meet the specific criteria. This specific inclusion criteria, according to mentor’s adjunct study, is that the patient be female, that the patient be willing to follow the study requirements and that the patient must have at least one or more of the specific indications, including 1) postmastectomy for cancer reconstruction; 2) a severe deformity which can include status post traumatic or a congenital deformity, including pectus carinatum excavatum tubular breast deformity or severe asymmetry such as in Poland syndrome, or finally breast ptosis, meaning sagginess to the breast which requires some form of mastopexy or breast lift. Final criteria can include replacement or revision from either reconstruction from breast or breast augmentation in which silicone gel implants were used previously.
There are exclusion criteria as well, which can be found on the Mentor Preoperative Patient History Record. These include the patient having any history at this time of an abscess or infection anywhere in the body. If the patient is pregnant or nursing, they are excluded from the study. If the patient has any symptoms of diagnoses of lupus or scleroderma, uncontrolled diabetes, tissue that is incapable of handling the silicone gel implant, including radiated tissue or psychological reasons.
If a patient meets any of the criteria as described above and the patient has a desire to either add silicone gel implants and/or continue with them after replacement, then the patient will need to fill out with the plastic surgeon the entire informed consent.
The informed consent will include specific details which will mark out the risks and complications associated with the surgery. These will include infection, hematoma or collection of blood, serous fluid collection (seroma), capsular contracture with scar tissue formation as well as anesthetic risks. Capsular contracture can occur with either silicone or saline and may require removal of the scar tissue, referred to as a capsulectomy, or release of the scar tissue (capsulotomy) in order to allow more volume space and room for the implant to move.
Silicone implants may deflate, rupture or leak and may require replacement. They may be more difficult to detect because although there is a rupture of the intracapsular shell, it may not be detected for many years. Mammograms and even ultrasound may not detect the rupture and an MRI may be required in order to get a more definitive answer. Extracapsular silicone migration can occur as well as this may lead to free silicone which migrates to the lymph nodes under the armpit or the axillary lymph nodes or into other parts of the body. If an implant is ruptured, it should be removed as soon as possible. Increased scar tissue formation certainly may occur as well as migration of the silicone gel to different parts of the body.
Other complications associated with silicone gel implants, include silicone gel bleed. This is simply the oil of the silicone migrating through small micro pores within the shell, which may bleed through and be trapped within the scar tissue around the implant. This may increase calcifications. Mammography interference and difficulty in detecting calcifications versus cancer may also be associated with silicone gel implants, especially when placed in the retromammary pocket (above the pectoralis major muscle).
In contrast, saline implants may be more user friendly in that 1) we’re able to change the fill volumes of these implants with women who have asymmetric breasts are able to titrate the volumes of the implants to even out the breasts to make them more symmetric. Saline implants also if they shall rupture are an all or none phenomenon and within several weeks it will be quite apparent that the implant is deflated. The fluid from a saline implant when placed preoperatively in a sterile environment will be absorbed or resorbed and should yield no harmful effects to the patient.
Capsular contracture certainly can occur with saline implants, although in my practice I have found it to be less likely than silicone gel, as there is no silicone gel bleed with saline implants.
In the future, silicone gel implants may be available to the general public. At this time, it is still under FDA review and although the advisor panels have approved the silicone gel implants to be reviewed by the FDA, there is no definitive answer at this time. In general, as in any surgery, the use of silicone versus saline implants must be tailored to the needs and specifics of each individual. It is important to choose the specific implant carefully. The patient once again needs to be included within the criteria outlined by Mentor and/or Inamed Corporation in the United States of America.
Tubular breast deformities are not all that uncommon. By definition, it is associated with herniation of breast tissue into the nipple areolar complex, constriction along the lower pole of the breast causing a poorly defined inframammary fold. Often the nipple areolar complexes are also lowered causing some degree of sagginess or ptosis.
Repair of the tubular breast can be performed by placing saline or silicone breast implants either through the subglandular or under the muscle with a dual plane technique. In the past implants were usually placed above the muscle in the subglandular pocket. However, presently Dr. Linder places the implant most commonly in the dual plane, two-thirds under and one-third over the muscle, depending upon the degree of the tubular breast deformity. If there is a very thick amount of glandular tissue subglandular retromammary placement may be preferable in order to allow some upper pole fullness along the medial sternal area (towards the middle of the chest cleavage area). If, however, the tubular breast is associated with minimal amounts of breast tissue, then Dr. Linder places the implants usually under the muscle medially in order to reduce visibility palpability of the implant edge.
Reconstruction of a tubular breast includes breast augmentation with saline or silicone implants, releasing the inframammary fold, the crease line underneath the breast, to a proper position and scoring of the lower pole of the breast in order to evaginate it outward, allowing it to become more rounded in shape. If there is a significant degree of sagginess, then a breast lift may also be required with a reduction of the size of the areolar.
Postoperatively, a tubular breast should be treated with an upper pole compression band which will allow relaxation of the upper portion of the breast, allow the implant to be inferiorly displaced and allow for the lower pole of the breast to become more rounded and less flattened in shape. The bands can sometimes be worn up to six to eight weeks, depending upon the length and time it takes to lower the implant to regain a normal rounded shape. Tubular breast deformity reconstruction is a challenging operation, but in the hands of a Board Certified Plastic Surgeon, can be a wonderful operation with a very satisfied patient.
The female patient presented is 26 years old and was looking to improve her breast appearance by increasing her breast volume and position. However, her thoughts about having a breast lift were concerning because of the potential scarring. During her examination, she showed a mild degree of breast sagging, and based on her expectations, a lift would be needed. After examining and listening to her goals, we agreed to schedule a primary augmentation and lift.
During her surgery, I placed 400 cc saline high profile breast implants. I overfilled the right implant to 440 cc and the left side to 455 cc to create fullness and symmetry. Because the implant alone would not elevate the breast enough and knowing her concern about scarring, I performed an incision type called the Benelli Lift to raise the nipples slightly.
As you can see, the patient is only four weeks post-surgery, but she has nice volume and symmetry, and she has a more youthful appearance.
The patient below is a 30-year-old female that came to me 5 months ago looking to improve her appearance of her breast. During her consultation she shared with me how she was seeking to enhance her shape and fullness. After listening to her expectations, we agreed to use 320 cc high-profile saline breast implant by Allergan.
During her augmentation surgery I created a nice tight pocket for the new implants and placed the 320 cc giving a nice increase anterior/posterior projection.
Below is the postop photos the middle one is showing only 7 days out and the one on the far right is now 5 months postop. She has followed the post op instructions and as you can see she is extremely happy with her new look.
The female patient presented was looking to have her breast implants removed and wanting to improve her breast appearance without placing new implants. During her examination, she expressed she was hoping to have a breast lift and reduction. After discussing her expectations, we agreed to perform an explantation (implant removal), mammoplasty (reduction), and mastopexy (breast lift).
The video below shows the pre-op marking where I go over the implant removal, breast reduction, and a full breast lift (mastopexy) using a wise pattern anchor approach.
During her surgery, I removed the high placed breast implants and performed a breast reduction (removing some tissue and skin to reshape and reduce the size of the breast) and a lift to bring the breasts to a higher and more youthful position.
The post-op (day one) photo shows a drain placed to help decompress the space around the pedicle that was created as well as wearing a Linder Bra to provide support after surgery. The patient is happy, and she has achieved a nice shape and symmetrical balance.
To schedule your consultation with Dr. Linder and learn more about breast implant removal, breast reduction, or breast lift, call our office at (310) 275-4513 in Beverly Hills or fill out our online contact form today.
The patient below is a 35-year old female requesting a primary breast augmentation. As you can see by the preop photo, both breast are small and nicely balanced. The patient was hoping to increase her size and fullness overall. After listening to her expectations, we selected to go with 225 cc Natrelle Inspira SRX breast implants. These SRX implants are silicone gel with a smooth shell surface and provides a nice fullest.
The postop photo is 12 weeks out, and she is happy with her upper pole fullness.
The patient to the left came into my Beverly Hills office looking to correct a previous augmentation. During her examination, it was apparent that she had capsular contracture (hardening of the breast) due to scar tissue around the implants. After listening to her goals, we scheduled a breast revision surgery.
Treatment of capsular contracture involves multiple steps to decrease the chance of recurrence. First, I remove the current implants and then perform a complete capsulectomy (removal of all the scar tissue). I then put a dermal mesh sling around the right implant to help prevent the risk of scarring again. I replaced the old implants with 560 cc SRX extra-full profile silicone implants, which have a smooth shell surface and will provide the patient with a fuller, rounder look.
The post-op photo to the right is now four weeks out. As you can see, her breasts are balanced (symmetrical), and she has a nice fullness.
Stuart. A. Linder, M.D., F.A.C.S. is a Beverly Hills plastic and reconstructive surgeon specializing in breast augmentation, liposuction, tummy tuck, and more.
Dr. Linder is certified by the American Society of Plastic and Reconstructive Surgeons and is a diplomate of the American Board of Plastic Surgery (ABPS).