Silicone vs. Saline…which is better for Breast Augmentation?

Many of my patients  who I see in consultation for breast augmentation surgery have questions regarding the benefits of silicone implants vs. saline. This is especially true since the huge media scare  back in the 1990’s claiming that silicone implants were the cause of  a multitude of health related issues.

First of all, silicone implants are safe. The  Institute of Medicine, a branch of the CDC (Center for Disease Control) wrote a position paper in which the safety of silicone breast implants were affirmed. The paper reviewed the research data on the topic, specifically two large studies, one out of Canada and another from the United States in which 10,000 and 15,000 women were followed for years to determine if there were long term health risks to women in whom silicone breast implants were used.  These studies were in progress well before the  alleged health  issues were raised in the infamous class action law  suit .  Silicone  breast implants were found NOT to be associated with any of these health  issues raised in the law suit, specifically auto-immune disorders. The federal judge involved in the litigation chose not to allow these studies to be brought into evidence .  The end result of the law suit was over 3 billion  dolloars  being  awarded against Dow-Corning , a huge chunk of which went to the  plaintiff lawyers.  It has been estimated by the legal community that the attorneys involved averaged $90,000/hour for their time.  Also, after the dust settled so to speak, the FDA got involved and placed a moratorium on the use of silicone breast implants for patients undergoing  breast augmentation strictly for cosmetic reasons (known as primary augmentation). Women undergoing any type of reconstructive procedure, including a breast lift (mastopexy) were allowed to chose silicone implants for their surgery.  My facility had an IRB  to use silicone implants since 1999. (IRB is special permission for  use of silicone implants for data gathering purposes). My patients and  I have seen first hand the remarkable benefits using silicone implants over saline for breast surgery. Not until the fall of 2006, after many years of gathering data did the FDA change their position and allow the use of silicone implants for strictly cosmetic reasons. At that time surgeons had to stress  to patients that the FDA wanted all patients using silicone implants to get an MRI scan three years after their breast augmentation surgery then every two years thereafter in order to determine exactly how long a silicone breast implant would last before they ruptured.  The FDA could not obtain adequate information in this regard and as of August 2011, the FDA has dropped this request with the use of silicone implants. Now woman have the freedom to chose silicone or saline for the breast augmentation surgery  knowing the facts regarding  silicone implant  safety. Science and not political hype and hysteria have won the day so to speak (finally!).

Now that the safety issue has been addressed, I can discuss the benefits as well as the downside of silicone  versus saline implants as they relate to to patient outcome  and  satisfaction.

Regarding the outcome, there is no debating the point that all things considered, silicone filled implants will provide a superior outcome compared to saline.  This is not to say that saline implants do not  do a very nice job  in enhancing the size and contour of  a woman’s breast  ( click here to view saline implant breast augmentation before/after), but saline implants fall short of silicone implants in subtle, but tangible  aspects.  First and foremost, silicone implants   provide  a more realistic and pleasing  feel  compared to saline and  silicone gel filled implants do not wrinkle as much as saline filled implants. (Click here to view silicone implant breast augmentation before/after)

Being able to feel (or more precisely, not being  able to feel)   the  implant post operatively is one of the major advantages of silicone filled breast implant over a saline filled breast implant.  Saline filled breast implants feel like a water balloon (exact words from many of my patients who have had revisional surgery to replace their saline filled breast implants with silicone filled breast implants).  Silicone gel just feels more like breast tissue. This is especially true with patients who have enough native breast tissue to cover the entire breast implant.  Post operatively a breast should feel and move  like a breast. This is much more readily achieved with a silicone filled breast implant than with a saline filled breast implant.

Silicone implants tend not to wrinkle as much as saline implants post operatively. Silicone gel is what is known as a cohesive fill material…the gel “sticks to itself” so to speak. In other words, when the implant is held in a position against gravity, all the gel will not run to the bottom of the implant as is the case for saline.   This  can be a significant difference between the two types of implants  for  patients who have  very little  native breast tissue  .  Generally if you can’t  “pinch an inch” of breast tissue then a silicone implant may be a better option.  Ideally there should be enough breast tissue to sufficiently cover the implant in its entirety. Patients  do not want to see the wrinkled edge of the implant six months post operatively when  she leans forward or along the sides of the breast, which is often the case with saline implants. This is not to say that silicone implants never demonstrate  visible wrinkling, but the incidence of this occurring is reduced with silicone implants.

Because of  silicone implants  decreased tendency not to show wrinkling, silicone implants may  be be placed in the submammary position instead of underneath the muscle in some patients who demonstrate minimal native breast tissue. Saline implants require more breast tissue to be adequately  covered than do silicone implants. Implant position (or placement)  is a whole discussion in of itself which is discussed fully in another blog, but placing the implant on top of the muscle  may allow for  less post operative pain, swelling, and decreases the recovery period.

Both types of implants are prone to failure (leakage or rupture) given sufficient time  after surgery. Implants,  like anything else do not last forever. If saline implants develop a leak, the saline will eventually leak out of the implant and be absorbed by the body.  The saline used to fill the implant is exactly what a patient receives intravenously so it is utilized by the body as fluid.. The breast will become flat or lose its prior shape and volume.   Data suggests 0.7% rupture rate for silicone implants at four years post operatively. It is difficult to quote an exact figure for silicone implant rupture rate over its lifetime, but it is thought to be under 10%.   I use to tell patients  saline implants have a 1-2% per year life of the implant rupture rate. In other words, if you have a saline implant for 10 years, then your implant has a 10 – 20% chance of failing. That seems to be more tangible, but now the manufacturers state  7-9% rupture rate for the lifetime of the saline implant.  If  a ruptured or leaking  saline implant is replaced before the capsule around the implant shrinks, it is a simple matter of replacing the saline implant under a local anesthetic. There is none of the original post operative swelling and discomfort. It is only a matter of caring for a fresh incision for a couple of weeks. If a silicone implant leaks or ruptures, because of the cohesive nature of the fill material  not all of the silicone gel will necessarily come out of the implant shell.  Also,  the silicone gel will not be absorbed by the body like saline.  The silicone gel which leaks out of the implant shell is contained within the scar tissue which normally forms around any breast implant( this scar tissue is known as a capsule). The breast may not deflate and shrink in size as would be the case with a leaking saline implant. Replacing the implant is still recommended, but the bottom line is that there is not urgency as in a saline implant. Some patients chose not to have anything done until problems arise. An MRI is the definitive method of diagnosing  silicone implant rupture, unfortunately 11% of MRI results will be read as a rupture when no rupture exists. This is what is referred to a a “false positive” result and is one reason why the FDA  backed away from recommending MRI followup in patients with silicone  filled breast implants. Patients sometime ask which implant lasts longer. The answer is: no one really  knows. Theoretically the silicone gel acts as a better lubricant inside the implant shell as compared to saline. This property of silicone gel is thought to prevent or at least prolong the occurrence  of  “fold flaw” leaks. A fold flaw in an implant is analogous to what happens if you take a soda can and repetitively  fold it back and forth upon itself. After  several times of doing this the can develops a tear along the crease or fold.  Hence the term “fold flaw”.

Both of the primary United States breast implant  manufacturers  (Allergan and Mentor)  offer comprehensive warranties on their products.  A pair of s aline or silicone implants are considered a single item so that is one implant  fails, the manufacturer will replace both implants free of charge  as lifetime warranties. Within 10 years of surgery, they offer $1200 to the patient to help reduce saline implant replacement surgery costs.  Both  offer additional  warranty in which they will provide an extra $1200 if the patient pays $100 insurance within thirty days of their initial surgery. These surgery costs are only covered for tens years, but the saline implant replacement warranty is for lifetime. Silicone implants will be replaced free of charge as a pair for lifetime just as saline. Both manufacturers have identical surgery cost coverage of $3400 for replacing their silicone implants in case of rupture. This is a lifetime coverage, unlike saline which is only for ten years.

It has  been my experience that if you follow a patient long enough,  some patients appear to  see a change in volume or be able to feel the  saline implant  compared to that of a of the silicone filled implant. This does not occur in all patients but I have had several patients over the years in which the patient and I  both thought that her saline filled implant was leaking or deflating only to find an intact implant at the time of re-operation. For some reason the saline filled implant seems to lose volume even though when I remove the fluid and measure it in the OR, the volume is exactly what I put in it several years before.

Both types of implants obscure mammogram visualization of the breast post operatively to the same degree.  The shell of the implants are identical.   It is the shell of the  implants which interferes with mammographic visualization of the breast. Whether the implant is saline or silicone filled is not relevant.  Whether the implant is above or below the muscle has more influence on how much breast tissue can be visualized on mammogram. Generally an implant below the muscle allows about 20% more mammographic visualization of breast tissue than if the implant is above the muscle.

Silicone filled implants come pre-filled and therefore require a slightly larger incision to place compared to a saline implant.  This slightly longer incision length can be looked at as a down side of silicone implants, but the additional length of the incision is so  inconsequential that this aspect of choosing  one type of implant over the other should really not be a deciding factor.   The larger incision length required for silicone implants  may be a factor however  if a patient is absolutely set on having her breast augmentation surgery via  the periareolar incisional approach. If a patient has a very small areola,  a large silicone filled implant may not be able to squeeze through  such a small opening.  Saline implants are empty and rolled up like as soft tortilla during placement. Once they are in proper position, the saline is added to the correct volume through a removable filler tube. This allows for a smaller length incision when utilizing saline filled implants.

Saline filled implants are adjustable in the OR in that the surgeon can  over fill the saline implant at the time of implantation.  Under  filling is never recommended by implant manufacturers  nor  is over filling by more than 30 cc’s (about an once).  The  adjust-ability of a saline filled implant may seem advantageous   in of  itself, but I do not think it  should not be a reason why a patient should choose  saline implants, all things considered. Silicone implants are pre-filled, but with the variety of widths, volumes and projections available your surgeon can choose an implant that is right for your specific needs.

Both silicone and saline implants come in different profiles (projection) for the same base width of any given implant. This allows for customizing outcome without having to resort to using an excessively wide implant. These implant profiles are demonstrated to each patient during their initial consult so each patient can visualize the difference. Saline high profile implants impart too much of a “ball” effect post operatively and I have stopped using high profile saline implants in my practice. Silicone high profile implants , on the other hand are fantastic options in the properly selected patient and are used extensively in my practice.

My practice experience has been consistent with the world wide plastic surgery literature in that there is no increased incidence of abnormal capsule formation with silicone filled breast implants compared to saline filled breast implants.  Many years ago this was an issue, but the current  manufacturing technology is so superior with  silicone gel filled implants that the issues of gel leakage causing abnormally hard, painful breast months to years after implantation is no longer a valid argument.

The final word on whether silicone filled breast implants are superior to saline filled implants come from the patients who have had the experience with both types of breast implants. I have  dozens and dozens of patients who have had saline filled implants initially but were  later exchanged for silicone filled breast implants. In each one of these patients the response was identical: my patients preferred silicone over saline. They made comments like “they (the silicone implants) feel like me, ” I can sleep on my stomach and I don’t feel like I’m on water balloons”, “my gynecologist couldn’t even tell I had implants” and the comments go on and on. Not one patient has ever voiced regret in changing from saline to silicone filled breast implants.

If there is a down side to silicone  breast implants it would be that they do cost more than saline, and this cost is universally passed onto the patient; sorry. Generally silicone implants cost about $1,000 more than their saline counter parts.

My  responsibility as your surgeon  is to fully inform  each patient of the risks and benefits of each type of implant and to make recommendations as to which type of  implant will provide the patient with the best outcome. The final decision  to use saline or silicone implants is always left up to patient.