The FDA removed its restrictions on the use of silicone gel implants in November, 2006, opening the door to a wider range of choices for women seeking breast augmentation surgery. In my practice, over 60% of patients chose silicone gel in the first year after they were made available. As the safety of these implants has become more and more accepted, over 90% of my patients choose silicone gel today. There are potential benefits to each implant.

Saline implants are inserted empty and filled by the surgeon during the procedure. This allows a slightly smaller incision and somewhat greater accuracy in correcting asymmetry in breast size since the surgeon can choose to fill one more than the other. Saline implants are less expensive, too, approximately $900.00 per pair less than silicone gel filled implants. If a saline implant leaks, it deflates and that breast loses volume, creating a sense of urgency for surgical replacement. Some patients enjoy the peace of mind knowing that it contains only sterile salt water and is quickly absorbed by the body. Others are distressed that a leak in the implant creates a situation of necessity to have replacement surgery. Saline implants feel stiffer in patients with very little breast tissue and the folds in the implant can more frequently be felt or seen, a condition called rippling. Also, saline implants look less natural in some patients, especially those with very small breasts before surgery. This is considered an advantage for patients who prefer a tighter, rounder, less “natural” augmentation. Although most of my patients request results that look natural and proportional, those who prefer a more spherical and visibly augmented look are often better served with saline implants. In my experience this is a more frequent request in younger patients, which is fortunate, since the FDA (without explanation) restricts silicone gel to individuals age 22 or older.

Silicone gel breast implants have changed dramatically since their introduction in the 1960s. Silicone can be manipulated chemically to be a liquid or solid rubber or anything in between. Earlier versions of the contained silicone gel were less formed and could flow out of a tiny crack in the implant. The earliest models could even “seep” through the intact rubber shell, a process called gel bleed. The newer implants, which are a fourth generation device, have gel so thick that, like Jell-O, it maintains its shape for a prolonged period, even if cut in half. The silicone rubber shell is far more durable too, further decreasing the risk of leakage. Current data show that over 94% of today’s gel implants are still intact at 10 years. Studies also show conclusively that silicone has no relationship to the development of any known disease or illness, one of the main factors leading to the FDA’s approval. The advantages of silicone gel breast implants include a more tissue-like quality which feels more like breast tissue, and a lower risk of feeling the implant folds or seeing them through the skin (rippling). Many patients feel that gel filled implants result in a more natural shape since they settle and move more like breast tissue than saline implants. Gel implants do require a slightly larger incision since they are pre-filled. Routine mammograms are still necessary for breast cancer screening and in addition, when the FDA removed their restrictions on silicone gel breast implants, they suggested that women with these devices consider an MRI scan after 3 years and again every two years to evaluate the surface of the implant. The importance of this in terms of patient health is debatable however, since the fourth generation silicone gel is so thick it would be unlikely for it to flow out of a small crack in the implant shell. Additionally, the MRI scan is not infallible, and there is the possibility of an inconclusive result and even the known risk of a false positive MRI scan which could create unnecessary confusion. It is my feeling that an MRI scan is warranted when there are unexpected or suspicious changes in the breast but that it is debatable as to the need for regular or frequent MRI scans as a method of surveillance. Additionally, as mentioned, current data show that there is no known illness or disease caused by silicone. Since it appears harmless, many physicians feel that it is of questionable value to obtain MRI scans in a problem free augmented breast. This may be a decision best left to a woman and her plastic surgeon, but the FDA’s position is to consider an MRI scan after 3 years, then every 2 years thereafter.

In summary, saline implants are less expensive, adjustable in volume and provide good results in most women with a reasonable amount of breast tissue to minimize rippling. Silicone gel implants feel more natural and appear to decrease the risk of surface rippling and in many instances appear, feel, and move more like actual breast tissue. It is my feeling that silicone gel provides the most “real” or “natural” breast augmentation. Saline implants go flat when they leak and replacement may be psychologically urgent. Silicone gel may require an MRI scan to detect failure.

Each woman must weigh these pros and cons to determine the choice of implant which is right for her.