Explore Plastic Surgery

Breast augmentation continues to be one of the most popular plastic surgery procedures because….the results are immediate and very gratifying for nearly every single woman that undergoes the procedure. Breast augmentation can be done with either saline or silicone implants, both of which work well and create identical results in the end. But there are a few disadvantages with either saline or silcione breast implants and patients need to understand what these are so they can make the best decision for themselves.
Saline breast augmentation has a long history of success and offers two distinct advantages. First, it is less costly than silicone implants and it is the only implant type that can be placed through a very small incision off of the breast in the armpit. Its single greatest long-term risk is implant failure. In others words, what would happen if the implant should get a small hole or tear in it. Implant failure is a good medical term but the practical outcome of this problem is better appreciated as deflation, In most cases, this will be immediate…creating the effect of a flat tire. There are some cases where a saline breast implant deflation can be slow, gradually getting smaller over weeks or months. But most of the time the deflation is relatively immediate and the change in breast size acute. Why this happens has nothing to with what the patient has done. If you were to get a high energy level of force delivered to your chest, such as a car accident or get kicked by a horse (to pick two extreme examples), that may be enough force to cause the implant bag to tear. But this is very unusual. The main reason that saline breast implants deflate is due to fatigue of the material that makes up the bag or shell of the implant. The constant movement and stretching of the implant eventually causes microscopic tears in the material which eventually leads to a hole or crack that goes through the thickness of the implant wall. Much like a tiny crack in a dam which eventually spreads and causes ultimate dam failure.
What is the likelihood that saline breast implants will deflate? No one can give an exact prediction for any patient. I like to tell my patients that it is not a matter of if…it is just a matter of when it will occur. That is the right mindset to have. You must accept that this may happen. I hope that it never does for any patient, but I know it will for some. According to one of the largest breast implant manufacturers in the U.S., their reported delation rates for saline breast implants was 1% at one year after surgery and 3% at 3 years after surgery in a very large study involving thousands of breast augmentation patients. If you apply simple math to this trend, that would be 10% (1 out of every 10 patients) at 10 years after surgery. So the risk of saline implant deflation is not irrelevant. And the concept that your breast implants will last a lifetime is not realistic. (possible yes, but not very likely) Plan for their eventual replacement is what I tell my patients.
The good news is that replacement of any deflated saline breast implant is much easier and less costly than the original procedure. And the manufacturers (currently) offer free implants for those deflated anytime during your lifetime and cash payouts to help cover the cost of replacement surgery should the deflation happen within the first ten years after placement.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Saline-filled breast implants typically have some amount of rippling or wrinkling which is not usually seen with silicone gel breast implants. (although it can still occur) This is particularly evident in women with thin skin and very little breast tissue. Implant wrinkling is felt on the bottom and sides of the breasts and can be seen as patterned set of lines visible through the breast skin. Breast implant wrinkling is usually most visible in certain positions, particularly when one is leaning forward or lying on your back. Wrinkles on a saline breast implant may be only a minor cosmetic issue (if you were informed before surgery) or might be a source of major unhappiness and be the reason to undergo revision surgery.
Rippling occurs as a result of the physical interface between the saline and the elastic silicone polymer shell . The exact reason wrinkling of the breast implant occurs has to do with how well the filler material coats the inside of the implant and bonds to it as well as its own viscosity. Water (or saltwater) flows easily and does not ’stick’ well to the inside wall of the breast implant shell, resulting in implant buckling and folding. This is a normal finding with saline breast implants and its presence is not abnormal or the plastic surgeon’s fault. Placement of saline breast implants above the muscle is also much more likely to lead to visible implant wrinkling in thin individuals as there is little breast tissue to cover the visible ripples and there is no pressure on the implant from the overlying muscle. Textured saline implants are particularly prone to rippling due to their thicker shell (harder for the water to push it out) and due to traction from the implant grabbing the thicker non-stretchable surrounding scar that it creates. The combination of textured saline breast implants above the muscle has the highest incidence of significant wrinkling issues.
Established ways to diminish the amount of wrinkling which can occur are to overfill the breast implant with more saline than the implant base size (increase the internal fluid pressure) and to place the saline breast implants under the muscle. (which puts more pressure on the outside of the implant). Both of these methods do lead to less wrinkling, but neither can completely prevent it. Overfilling a breast implant with too much saline will make it feel more firm than normal breast tissue, although this is generally well accepted by most patients. The best approach for prevention is to use non-textured saline implants placed under the muscle which are then filled 25 to 50cc more than its base size. While all implant wrinkling can not be prevented with saline fills, a significant reduction can be seen in most patients with this approach.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

One of the known complications of the use of saline breast augmentation is the lifelong potential of deflation of the implants. Often referred to as rupture or developing a hole in the implant, the term deflation is more appropriate as it occurs without warning as the implant just slowly deflates over hours or days. (and sometimes weeks and months) While this is not a rare occurrence, there is a fair amount of misinformation as to how and why saline breast implants deflate.
First and foremost, the actual occurrence of saline implant deflation is around 1% per year for the lifetime of the implants. This would mean that 1 in 10 saline breast implants will undergo deflation within 10 years after placement. That is not a rare risk and every patient who considers or has them should understand that it is not a question of whether saline breast implants will deflate, it is only a question of when. In my opinion, a 10 to 20 year lifespan would be considered good and the younger a patient is who gets them, the more likely they will need replace them. I think patients under the age of 50 should mentally factor in that they will probably require replacement surgery of one or both breast implants in their lifetime.
Secondly, saline breast implants fail due to fractures occurring in the plastic shell. This leads to a full-thickness hole which causes the leak. This development is a natural occurrence which will eventually occur due to the wrinkling of the implant shell (from the saline fill) that causes fatigue fractures at the microscopic level of the material. It is not a result of anything the patient usually has done and it is not their fault. It is an inevitable biomaterial development.
Thirdly, most saline breast deflations are relatively acute. Meaning the change in the outward appearance of the breast usually occurs fairly rapidly over hours or a day or two. While there are cases where a ’slow’ leak occurs over weeks to months (partial deflation), this is not that common. There may or may not be some pain associated with the deflation which is the result of the normal scar around the implant (capsule) shrinking onto itself (contracting) as it has lost its underlying support. Most certainly, all saline breast implant deflations result in very discernible external changes with a clearly smaller breast, bottoming out of the lower breast skin, and very significant asymmetry to the opposite side.
Saline breast augmentation is a very good procedure that works well. The patient must understand, however, that the saline breast implant has a limited llifespan and eventual replacement will be needed in many patients. The deflation of a saline breast implant is usually unexpected, appears rapidly for no reason, and constitutes a ‘cosmetic emergency’ to which patients appreciate a rapid replacement solution.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Breast augmentation remains one of the most popular plastic surgery procedures overall and one of the most commonly performed plastic surgery procedures for women under the age of 35. Breast augmentation is a fairly ’standard’ procedure in terms of how it is performed and the time it takes to perform it. In my hands, a primary breast augmentation procedure takes one hour to complete, from entering the operating room to being awake headed to the recovery room. Much of the cost of breast augmentation is, therefore, fixed including the cost of the breast implants themselves (silicone gel breast implants cost more to purchase than saline breast implants) and the use of the operating room and the anesthesiologist’s charges.
Because breast augmentation costs are predictable, many plastic surgeons freely publicize their fees to perform the procedure. When seeing a breast augmentation fee stated, make sure the fee you are seeing is all-inclusive. Often times, touted breast augmentation fees only list the surgeon’s fee and you have to read the fine print to see the additional costs of the breast implants, operating room, and anesthesia. If the fee has an asterik (*) by it, you automatically know that the listed fee is only a tease and misleading.
Because breast augmentation is a very predictable operation in terms of costs and execution, unlike most other plastic surgery procedures such as facelift, liposuction, etc., the listing of breast augmentation costs for any practice is not unreasonable. Also, one of the most common questions that patients have about breast augmentation surgery is the cost. It is often the first and only question they may have when making a phone call to your office or an e-mail inquiry to your website. For these reasons I, like many plastic surgery practices, prefer to publicize my fees for breast augmentation. In my practice, the all-inclusive costs for silicone gel breast augmentation is $5,999 and $4,799 for saline breast augmentation.

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana

Since 2006, siicone breast implants have been approved again for breast augmentation. These are new-generation silicone breast implants that are filled with a new gel formulation of silicone that promises not to leak or bleed and be more durable than the old silicone breast implants that were used from the late 1970s to 1992. The long-term data on these newer silicone breast implants is relatively short, while we have 15 years of long-term data on saline breast implants. How, then, do they compare?
In a recent February 2008 editorial by Dr Rod Rohrich, Editor of Plastic and Reconstructive Surgery journal, he does exactly that….comparing the scientific data of both types of breast implants. Here are the highlights of his analysis:
1) Patient satisfaction is high with either saline or silicone breast implants.
2) Saline breast implants need a smaller incision to be placed and cost less than silicone.
3) For breast cancer imaging, both breast implant types require additional views on
mammography to adequately image the breast.
4) Saline implants have a decreased capsular contracture and rupture rate than
silicone breast implants.
5) Saline breast implant rupture can be seen, silicone breast implant rupture can not be
seen on the outside and requires an MRI to detect.
6) Breast augmentation is not a forever, one-time operation. Many patients will eventually
require revisional surgery at some point in their remaining lifetime, often to replace their
implants.
These findings support what I tell every breast augmutentation consult. Neither saline nor silicone breast implants are perfect, each has its own unique set of advantages and disadvantages. Both of them will do the job and do it satusfactorily, make the breasts bigger. Saline breast implants have an exceptional safety history, are less expensive, and can be placed through a small incision that is away from the breast (armpit)…….but one has to accept some implant rippling/wrinkling, less of a natural feel, and the immediate deflation of the breast should the implant rupture. Silicone breast implants are not as well studied, require a bigger incision in the crease of the breast fold to place, and are more expensive…. but with the benefits of a more natural feel, virtually no rippling, and lack of any breast changes (in the short-term) if the implant should rupture.
How does a patient choose? I tell patients make your choice based on which of their disadvantages you can live with the best. Both saline and silicone implants work for breast augmentation…which of their disadvantages is more acceptable to you?

How to Choose between Saline or Silicone Implants in Breast Augmentation - Dr Barry Eppley in Indianapolis

Since silicone breast implants have been re-introduced to the commerical market in late 2006, this has provided women with a choice in breast augmentation. While some plastic surgeons may favor one type of breast implant over another, the reality is that both breast implants have their advantages and disadvantages. Whether one type of breast implant is better than another depends on what implant characteristics the patient can accept. My mission as a plastic surgeon is to educate my potential breast augmentation patients as to the different features of saline vs silicone breast implants. It is up to the patient to decide what breast implant features they desire. Or to put it more simply…..which of the breast implant liabilities (disadvantages) can you live with the best? (the potential health-related issues of silicone breast implants has now been sufficiently refuted and therefore do not enter into any discussion here)

One important concept to grasp…..both saline and silicone breast implants can do the job. Both work and can look equally well. One type of breast implant doesn’t necessarily look better than the other, contrary to the suppositions of some. However, the choice of one implant over the other does control several issues about the breast augmentation procedure……and besides choicing an experienced plastic surgeon is the most important decision about your breast augmentation procedure.

Saline and silicone breast implants differ in the following diametric ways. Saline breast implants are surgically inserted deflated, silicone breast implants are inserted at their listed volume. Therefore, saline breast implants can be put in through a very small incision in the armpit while most silicone breast implants need a larger incision in the lower fold of the breast. Saline breast implants will develop a phenomen of rippling, most of which can be felt at the bottom and sides of the breast (in very thin patients this rippling can be seen), silicone breast implants remain smooth and do not develop this cosmetic rippling issue. If a saline breast implant fails, it is known as deflation as the implant becomes like a flat tire. While this causes no harm, it is dramatically seen and is a cosmetic ‘emergency’ so to speak. If a silicone breast implant fails, it is not called deflation but is known as silent rupture. In other words, there is no visible sign that the implant has ruptured as it does not change shape or deflate. (since what is in it is not water, but a jello-like substance that does not flow) It is possible that a patient may never know that it has ruptured as long as the breast is soft, looks good, and is pain-free. What this suggests is…..the likelihood of the need for breast implant replacement due to ‘failure’ over one’s lifetime is most likely less for silicone than for saline breast implants. The last difference between the two is cost. While surgeon’s fees and other surgical expenses may differ, the purchase cost of a pair of silicone breast implants is higher than for saline. Sinc most plastic surgeon’s merely pass the cost of the breast implants onto to the patient in the overall fee, silicone breast augmentation is more expensive than saline breast augmentation.

In summary….which liability can you live with……..saline breast implants and the issue of rippling and possible deflation……or……silicone breast implants which are more expensive and require a bigger incision to insert.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Anatomy of a Breast Implant in Breast Augmentation - What’s It Made Of?

While patients have a major choice between saline or silicone filler materials today in breast implants for breast augmentation, there is another component of a breast implant that is frequently overlooked and can have a big impact on how a breast augmentation feels….and that is the bag or shell which contains the filler material. And occasionally I do have a potential breast augmentation patient ask about the shell, particularly if they have some ‘old fears’ about silicone breast implants.

The shell (containment bag if you will) of a breast implant is made up of silicone oil (technically siloxane), but it is a highly cross-linked formulation giving it a rubbery or rubber consistency. From an elemental standpoint (for you chemistry enthusiasts), silicone does contain some silicon atoms (semimetallic element #14) but it is combined with oxygen and methyl groups which give it characteristics completely different from silicon on the periodic table. When cross-linked together to create a solid, it is known as polysiloxane. And it can be made in any consistency from an oil (what was used in antiquated breast implants and is now still used in ophthalmology for eyeball fluid replacement and in some countries as a soft tissue injectable filler) to any stiffness of a rubber material. As a result, silicone rubber is used in a large number of medical devices and implants. In plastic surgery, for example, many facial implants (cheeks, chins) are made of it. Silicone rubber has been consistently proven to be safe…..which is particularly evident from the intense evaluations done of it from the breast implant issues from the 1990s. It is fair to say, silicone breast implants have been the most studied medical implants in history…and it has now been proven that women with silicone breast implants are no more likely to develop ill health than women without breast implants. Which is why they are now again approved by the FDA and are now widely used in breast augmentation again.

But back to the shell, it is silicone and the shell is the same for either silicone breast implants or saline breast implants. When there is only one shell, it is called a single lumen breast implant, which is by far the most commonly used. In single -umen breast implants, it is only what lies in it that differs. When saline is used, the breast implant is placed ‘deflated’ and filled after it is in place. This is why saline breast implants can be placed through very small incision off of the breast. (through the armpit or bellybutton) It is like inserting a burrito through a small hole. In silicone breast implants, the semi-solid silicone material is placed in the implant at the factory, therefore they are pre-filled. As a result, a larger incision somewhere on the breast (lower fold usually) must be used to get them in place.

As opposed to a single-lumen breast implant, a double-lumen breast implant has a shell within a shell, or a ‘bag within a bag’. There is a smaller bag that floats inside a bigger bag. Usually the big or outer bag (the one you would hold in your hand) contains silicone (for the softness and lack or ripples) and the smaller inner bag contains saline (which can be added to at the time of surgery to offer some adjustability of size.The inner lumen (bag) is filled during surgery through a valve in the implant. This implant type combines the benefits of saline and silicone fillers in one breast implant.

As for filler materials, saline is just salt water. (although this is not entirely accurate, saline is 0.9%, salt water is around a 3% concentration of salt solution) Even if it leaks out, it is as safe as water. Silicone gel (oil is no longer used) is much like jello. It is still silicone, but it is somewhere between oil and rubber in consistency. If you cut a silicone gel implant with a knife and hold it upside down, it will act like meringue pie. The gel is ‘cohesive’ and it stays together. So if you get a hole in your silicone gel breast implant, it is not going to leak out. Increased firmness of the silicone gel is what makes a ‘gummy bear’ implant. It is still silicone but it is firmer or stiffer. Whether differing firmness of the silicone gels is any advantage in breast implants is a cosmetic matter, not any safety issue.

Remember that breast implants are medical devices that are highly regulated by the FDA today and are manufactured with high standards. That being said, I never tell a patient that a breast implant is permanent. They have a lifespan and can always fail and need to ber replaced. What makes a breast implant need to be replaced is failure (tear, rupture) of the shell. This would obviously be kost evident in saline breast implants (i.e., a flat tire) vs a silicone breast implant (which may not even be detectable as it doesn’t change size.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
http://exploreplasticsurgery.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis