Breast augmentation surgery might seem straightforward and uncomplicated. It just involves placing an implant into a pocket on the chest wall and then closing the skin, right? The truth is that choosing the right size and shape for the implant, and creating a perfectly tailored pocket require a keen understanding of anatomy and aesthetics. It’s only with extensive training and experience that a surgeon is able to determine the right width, projection, and position of the implant. The surgeon should be the patient’s guide in making these decisions. But choosing the type of implant is usually a team effort, and it always helps if the patient is familiar with the available options.

Traditionally there have only been two categories of breast implants: saline and silicone. Saline implants have silicone shells and are filled with biologic fluid. Silicone implants not only have silicone shells, but are also filled with silicone gel. Both types of implants are used to enhance the breasts, but they perform very differently, both inside and outside the body. But now there is a new generation of implant—The Ideal Implant—that’s changing the game (more on that later). But first, let’s look at the pros and cons of saline and silicone.

THE PROS AND CONS OF SALINE IMPLANTS

Saline implants have a very good reputation in terms of safety, and have never been connected to any health conditions. But the problem with them is that they look and feel like what they are: water balloons. This means that in women who have little of their own breast tissue, the effect of saline implants can be pronounced, to the point that ripples in the implants can be felt and even seen. Because of this less than ideal aesthetic effect, saline implants have fallen out of favor among many surgeons. This is where silicone implants come into the picture.

THE PROS AND CONS OF SILICONE IMPLANTS

Silicone implants are gel-based and soft, and they look and feel like natural breasts. From an aesthetic standpoint, they’re far superior to saline implants, and they perform better cosmetically over time. The problem, however, is that though extensive research has failed to prove them to be dangerous, they have been related to numerous health conditions.

The first major issue with silicone implants surfaced in the 1980s, which led to a moratorium in its use in 1992. The concern was that the implants were possibly linked to certain connective tissue disorders. But the FDA carried out a subsequent evaluation, and found no proof of danger. So, the implants returned to the market in 2006.

Since then, silicone implants have undergone several changes. The most significant variation has been the development of the form-stable, anatomically shaped “gummy bear” implants. These implants are teardrop-shaped, so they have to remain upright in order to maintain the shape of the breast. To that end, they have a textured surface that prevents them from turning sideways. Silicone implants are more solid, so they don’t leak even if they rupture.

While this has its benefits, there is potential for a “silent rupture”. When silicone implants tear, they leak into the implant pocket. The gel usually stays put within the scarred capsule, but because nothing gets absorbed, most patients do not know that their implants have popped. This is why silicone manufacturers recommend having an MRI every few years to check on the implants. But because of the time and money needed for these check-ins, many patients neglect to keep up with them. Because of this, rupture rates are likely underestimated. But given the data we do have, we recommend that patients have their implants changed every 10 years. The long-term effects of ruptured implants aren’t definitively known, other than the frequent development of granulomas—scarred balls of silicone that turn into firm lumps on the chest.

Regardless of the potential of rupture, these textured form-stable implants are increasingly popular. Many surgeons believe that the texturing prevents scar contracture around the implant, and that the anatomic shape produces a more natural appearance. However, there is no conclusive data that proves the prevention of contracture, and blind studies on cosmetic results also failed to identify any benefit because of the shape.

On the other hand, a new health concern has emerged in recent years. An extremely rare form of cancer called ALCL has been detected in a very small number of patients, many of whom have had silicone implants placed in the past. Of these patients, a significant number have textured implants. It’s still difficult to draw a definitive link between textured implants and ALCL, however, since the number of patients with implants who have been affected by the disease is so low. Though we still don’t have a conclusive answer, the possibility of a link is driving a tremendous amount of research on the subject.

A NEW TYPE OF IMPLANT: THE IDEAL IMPLANT

I’ve met several colleagues over the years who exclusively use saline implants. Their reasoning is simple: they accept that the cosmetic outcome is inferior, but they believe that this can be offset by precise surgical technique and improved patient safety. Plus, they don’t want to have to deal with monitoring or cleaning up ruptured gel, which truly becomes an ooey, gooey mess. In general, if saline implants looked and felt more natural, they would be widely preferred by patients and surgeons alike. This leads us to a new generation of implants, which seeks to improve upon the older technologies for safer and more aesthetically pleasing results.

The Ideal Implant, developed by a plastic surgeon and launched in 2014, is a multi-chambered saline device with a completely different structure. It’s effectively a saline implant buried within another saline implant, with multiple baffle shells between the two, which distribute forces around. The end result is a dome-shaped implant, unlike older bubble-shaped implants. This shape has a more natural look, as well as a lower rupture rate. The Ideal Implant is firmer than gel, and therefore doesn’t feel as similar to breasts as silicone does, but it performs well from an aesthetic standpoint, and it produces overall excellent results.

IS THE IDEAL IMPLANT ACTUALLY IDEAL?

When I teach, I always tell my residents that the answer to the question “Is there a better way?” is always yes. In order to offer the best to your patients, you have to be open to innovation, but you also have to approach it with a critical eye. To that end, I began using the Ideal Implant with a hopeful spirit, imagining that if the aesthetic results were good, this could in fact be an optimal option for many of my patients. I was surprised at what I found.

Overall, using the implant is not more difficult from a technical standpoint. The shape is different, so the pocket has to be tailored slightly differently to have it sit just right. And visually, the firmer consistency allows for added perkiness to the breast. What surprised me was that visually, I don’t think you can tell the difference between the Ideal Implant and a silicone implant (though blind studies would have to be performed to prove this). The feel is slightly firmer and less fluid than traditional gel, but the potential benefits may outweigh this fact in many cases. And for some patients, the slightly firmer and more resilient contour might actually be preferable, especially over time.

Having performed a large number of breast procedures, and having used all types of implant devices, I can say that what we have had up to now is good, but not optimal. The Ideal Implant is a saline device that looks just as good as silicone, without the risk of health concerns. It has the lowest rate of rupture of any implant, requires no monitoring, and has no known association with any health conditions.

That being said, I would caution prospective patients interested in this technology to choose their surgeon wisely. Not many surgeons have had access to this device, and therefore few are experienced with it. At this point it’s still somewhat of a trade secret, and must be handled with care to get the best results. But for the right patient in the hands of the right surgeon, the Ideal Implant rises leaps and bounds above many previous technologies. And if the ongoing studies on texture-associated health risks do prove a definitive link, there will be a lot of relieved, perky-breasted women out there glad they made the best choice.

Sophie Bartsich MD FACS

as featured on CharlottesBook.com