For many reasons, I have always been a strong proponent of placing breast implants behind the muscle (submuscular) versus in front(submammary) in breast augmentation surgery. These include better support and soft tissue coverage of the implants, lower risk of capsular contracture developing, a softer and more natural overall appearance and feel. An even more important reason is that the breasts can be better assessed on mammography when the implants are situated behind the muscle rather than in front.
Rarely, will I ever place breast implants above the muscle and when I do, it is usually as an exchange for someone who has had reasonable results with their implants situated in this location. Body builders are another exception.
It is amazing to me that there are still many physicians who place a majority of their patients’ implants in a submammary pocket. Many of these happen to be non-plastic surgeons who find that performing the procedure is easier this way and therefore dismiss or ignore important aesthetic issues and outcomes.
Over the years I have seen countless poor results from saline implants placed above the muscle in women of all ages, a situation which is exacerbated by those with thin skin. Even more disheartening are those women in their 20’s who have sustained permanent damage by what I consider to be very poor “choices” by their surgeons.
The following video illustrates one such individual who is in her mid 20’s. Note the severe static and dynamic rippling, skin stretching and very poor cosmetic appearance.
If you would like additional information on breast implants, breast augmentation or any other plastic surgery procedure that I perform or to schedule a consultation, please call my office at 480-451-3000.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
All my patients who are considering cosmetic or reconstructive breast surgery procedures that involve the placement of breast implants are given the choice of using either silicone or saline implants. This includes women contemplating a breast augmentation, breast lift with implants, breast implant exchange and breast reconstruction. During their consultations, I extensively discuss the relevant issues regarding both types of implants such as durability, aesthetics, concerns and risks and they also are able to closely examine and feel each one. Ultimately, they decide for themselves which one they want: silicone or saline.
Silicone breast implant
Virtually all of my patients ultimately select silicone implants for their procedure, whether it is for aesthetic or reconstructive reasons. The very few cosmetic patients who do choose saline implants do so because of the cost differential: they are around $1,000 less per pair. The aesthetic outcome and satisfaction of my patients from these procedures irrefutably supports the far greater superiority of silicone implants as compared to the saline ones and this is true for both cosmetic and reconstructive procedures.
This preference has been borne out in the medical literature including a multicenter study just published in the November issue of “Cancer”. This study carefully examined and analyzed the responses of 672 women who had undergone post-mastectomy breast reconstruction using either saline or silicone implants at one of three major institutions in this country. The findings were statistically significant in that the level of satisfaction was much greater in those women who selected silicone implants to be used in their reconstruction as compared to the saline ones.
I find it amazing that so many people who have had or who are contemplating breast augmentations are under the false impression that breast implants should be changed every ten years. Did their plastic surgeon impart that advice to them or did a friend who had it done misinterpret some information? Or, did they read it somewhere on the internet?
This is absolutely a “young” wives tale, an urban (suburban and rural) legend without any factual basis. There is no fixed period of time after a breast augmentation or mastopexy with implants at which point breast implants should be replaced. Some implants may last only 5 years or even less (rare) whereas others may remain intact for thirty years or more.
In general, I inform my patients who are considering breast enlargement surgery that breast implants, though quite durable, are not “permanent” devices that will never need to be exchanged or removed. Given enough time, probably all of them would eventually need to be replaced. It is my experience that the silicone implants do last considerably longer in comparison to saline implants. There are also differences in implant lifespan that are manufacturer dependent.
Let me repeat this again so that there can be no confusion:
There is no rule or evidence that breast implants need to be replaced every ten years.
If you want more information regarding breast implants, breast augmentation or any other plastic surgery procedure that I perform or if you would like to schedule a complimentary consultation with me, please contact my office at 480-451-3000.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
size change – usually to increase the implant volume and therefore the breast size; rarely to decrease
to modify the breast configuration such as to make them more projecting or less wide
to switch from saline to silicone implants; rarely, silicone to saline
replace a ruptured breast implant
in the course of treating one of a variety of aesthetic breast issues such as drooping or capsular contracture, replacing older implants with newer ones.
The most common reason for implant exchange is that a woman is unhappy with the selected size and wants to be significantly larger. It is fairly infrequent to desire a smaller size and this is often due either to the surgeon placing a far too large implant initially or the patient gaining a considerable amount of weight resulting in a marked enlargement of breast tissue.
In my practice, it is fairly rare for my patients to desire a change their breast implant size and if they do, it is usually years later. Why can I keep this rate extremely low? When evaluating my patients in consultation, I listen carefully to exactly what they want or think they want. I also measure and size them in the office, have them try on a variety of implants, and show them photos of other patients to provide them with a greater understanding and visualization. During surgery, this is fine tuned, as I will employ temporary implants in order to assess the effects of various sizes and configurations.
By offering many different styles of breast implants, I can customize the appearance that would be most appropriate and desirable for my patients. For example, patients who are very narrow and desire significant projection would be best served with higher profile implants whereas women who are broad with a moderate amount of breast tissue present may benefit more from moderate profile implants. Many of the patients that I perform implant exchanges on were done elsewhere and indicated that they were never offered or explained the options.
It is essentially unanimous that women prefer the silicone implants over the saline ones as they feel similar to breast tissue. When switching between fill materials, virtually all go from saline to silicone whereas the opposite is almost never performed due to aesthetic issues.
During the moratorium imposed by the U.S. Food and Drug Administration between 1992 and November 2006 that limited specific uses of silicone breast implants, women who wanted to have a breast augmentation could only be offered saline breast implants. Since the end of 2006, silicone breast implants have once again been available without restriction for all women desiring breast surgery. This includes for breast augmentation as well as breast lifts (mastopexy) with implants, breast reconstruction and those who want or need to exchange their implants for different ones.
Having been in plastic surgery practice for over 22 years in Scottsdale and Phoenix, Arizona, I have long been involved and dealt with and witnessed the multitude of factors and issues regarding silicone and saline breast implants. Prior to 1992, my patients used silicone implants exclusively and were quite happy. During the period of the moratorium in which all my breast augmentation patients and some of my mastopexy and breast reconstruction patients utilized saline implants, I noted that the aesthetic results and level of satisfaction with the naturalness of outcome were decreased and compromised compared to results with silicone implants.
This sentiment came as no surprise. Why? Silicone breast implants feel very natural and “soft”, like breast tissue, so that when they are in place, it often is very difficult to discern their presence particularly for the non-professional. Saline implants, on the other hand, can often be detected, either by sight, feel or both. This is exacerbated in very thin patients who often have “rippling” seen through their skin. These issues and others such as deflations do detract from their popularity. In patients of mine who have had both types of breast implants, every single one of them preferred and were far more satisfied with the silicone ones.
In the more than 3 year period since the lifting of the moratorium on the usage of silicone breast implants, virtually none of my patients select saline implants for their breast surgery which translates to around 99% silicone usage. For the rare few who do, it is only because of the lower cost of the saline implants.
Unlike with silicone implants used in breast augmentation, the diagnosis of a ruptured saline implant is usually quite easy and apparent. Most of the time there is a rapid and dramatic decrease in volume of the implant and, therefore, in the size of the affected breast. This can occur in a matter of a few hours to a few days though I have had a few patients who have noted a very gradual decrease in size over a period of even several months.
What happens to the saline? Your body will absorb the fluid which is harmless. As it does, your breast will further decrease in size.
Once it is apparent that the implant is ruptured, I recommend that the situation be addressed sooner than later. The reason for this is that the tissue which had been previously stretched out will contract around the deflated breast implant over time and form variable amounts of somewhat constrictive scar tissue. This can make it more difficult to reacquire the level of symmetry that had been present prior to the deflation.
The plastic surgery options available for treatment of a ruptured saline breast implant following a breast augmentation fall into four general categories:
1. Replace just the deflated implant.
2. Elect to undergo a bilateral implant exchange. With this approach, one can also change size, style and switch to silicone implants
3. Remove both breast implants (also known as bilateral explantation).
4. Do nothing at all. This option is almost never selected.
In your consultation, I would discuss each of the above options in detail including the pros and cons in order to allow you to make an informed decision.
There are many decisions to be made when contemplating breast augmentation surgery such as implant size, shape, projection type, placement behind or in front of the muscle and saline versus silicone. Another factor to consider is the surface characteristics of the implant – smooth or textured. The first generation of breast implants that were used beginning in the 1960’s had a smooth outer surface. Over time, a significant number of these women developed firmness around the implants called capsular contracture. In the 1970’s, it was discovered that placing a thin layer of textured polyurethane foam around the implants resulted in a much lower rate of this contracture developing. The aesthetic results were superior both in feel and appearance to those that did not have this outer layer. These polyurethane implants remained quite popular until they were voluntarily removed from the market in 1992 due to theoretical concerns of long-term safety of the polyurethane itself.
Implant manufacturers sought to simulate these results by incorporating the texturing within the silicone outer shell of the implants without the need for polyurethane. These began appearing around 1986 from a variety of manufacturers and are still being offered today along with the smooth surfaced ones.
So, which is the better choice? The answer is not exactly straightforward. It may depend on several factors as well as on physician preference. Research data on textured versus smooth implants at times has been inconclusive with regard to the development of capsular contracture. For implants placed above the muscle (submammary), there may be a lower rate of firmness developing when the textured surfaced ones are used. However, textured saline implants in this location are associated with a high rate of rippling and irregularities of the skin contour, severely compromising the aesthetic result as compared to the smooth surfaced ones. This can also create discomfort in the breast where the edges of the implant are poking into the skin. The implant may also have a shorter life span.
Research results for the implants placed behind the muscle (submuscular) are less clear. There may be slight differences in the capsular contracture rates and durability between the textured and smooth implants, whether they are silicone or saline.
So, what do I recommend from my years of experience? For several reasons, rarely would I place an implant above the muscle. If I did, it surely would not be a textured saline one! My choice for saline implants behind the muscle is also smooth because they clearly provide a better aesthetic outcome.
Why saline implants placed above the muscle are not recommended - Frontal view (not my patient!)
Why saline implants above the muscle are not recommended - Oblique view (not my patient!)
Both smooth and textured silicone implants placed behind the muscle can yield great results. I base my recommendation largely but not solely on the dimensions of the implant that I am looking for. The textured and smooth implant configurations as designed by the manufacturer of preference, Allergan Corporation, are slightly different throughout the range of sizes with the latter tending to be slightly more projecting and less wide. If someone had a history of capsular contracture, I would more likely consider a textured surfaced implant in that situation.
I find that implant surface type is a non-issue with my patients. They will defer to my recommendations here. After all, they have much more important decisions to make. Like implant size…!
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
Although breast implants can be very durable, given enough time, they do not last forever. Over time, the cumulative effects of normal intrinsic and extrinsic “wear and tear” will affect the strength and integrity of the implant shell. Silicone implants do last noticeably longer as compared to saline implants.
What are some of the factors that can reduce the lifespan of implants? High impact trauma directly to the breast can significantly stretch and weaken the implant shell or even cause it to disrupt resulting in implant rupture. Common mechanisms for this include car and motorcycle accidents, major falls and even sports injuries. Nevertheless, I have evaluated and treated many women over the years whose implants have survived serious motor vehicle accidents including steering wheel breaking head-on collisions, being thrown from motorcycles, getting hit in the chest with batted softballs or thrown footballs, etc.
Anything that can markedly increase the pressure placed on the implants, sustained or intermittent, may predispose them to premature rupture. This can include extremely aggressive implant manipulations and massage, capsular contracture, and closed capsulotomies whereby the surgeon tries to treat the capsular contracture by intensely squeezing the breasts hoping to tear the scar tissue causing the firmness. (This is no longer an accepted practice because of the now known risks of premature implant rupture.) Rarely, very compressing and aggressive mammograms can precipitate an earlier rupture. This is more likely to occur with much older implants, particularly earlier generation ones that were not nearly as strong as the implants available today.
Penetrating injuries into the breast such as a result of trauma can pierce the implant envelope resulting in loss of integrity. This can even occur during a routine elective breast biopsy where a needle is inserted too deep, penetrating into the implant.
Studies have shown that breast implants subject to considerable forces at the time of insertion, will have weaker envelopes potentially leading to premature failure. This can occur by the plastic surgeon trying to insert a large silicone implant through a very small incision. Damage caused by surgical instruments at the time of surgery can also result in early deflation.
Saline implants that are under filled below the manufacturer’s prescribed amount, have a higher rate of failure. An example of this is a 420cc saline implant with a recommended fill range of 420 – 450cc that is only inflated to 375cc. Under filling will cause implant folds and creases that will ultimately weaken the envelope resulting in tears and, therefore, deflation. Moderately overfilling above the recommended range probably has little or no impact on durability.
Whether used for breast augmentation, mastopexy or breast reconstruction, breast implants are very durable. Their presence should not influence, within reason, “normal” activities of daily living.
Smooth (left) and Textured (right) Silicone Implants
Smooth (left) and Textured (right) Saline Implants
