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Scott L. Replogle, MD, is a plastic surgeon with 25 years of clinical experience in the Boulder, Colorado area. He is certified by the American Board of Plastic Surgery and is a member of the American Society of Plastic Surgeons and the American Society of Aesthetic Plastic Surgeons. He holds an undergraduate degree from Princeton University and received his MD from Rush University in Chicago with surgical residency training at the University of Colorado and the University of California San Francisco. He is in private practice specializing in breast surgery and cosmetic procedures under local anesthesia.

Breast Implants: Silicone or Saline – Which is better?

Breast implants are synthetic devices used to substitute for breast tissue to either fill out a natural breast or replace the volume of a reconstructed one. Breast augmentation with implants is the much more common use and is one of the most common cosmetic procedures carried out by US plastic surgeons.

Breast implants come in two basic types but are actually very similar. The implants referred to as “saline” are made of a silicone rubber shell filled with the same fluid used in some of those IV bags hooked up to patient’s veins that run directly into the bloodstream. “Silicone” breast implants have the same silicone rubber shell but are filled with silicone gel that has a consistency between jelly or jam and a gelatin pudding.

For 13 years until two years ago, silicone gel implants were effectively banned from the US market by the FDA. Women or their surgeons could not choose them except under limited and specialized conditions. The reasons for this would make the subject of another column, but fortunately silicone gel implants were available in most of the rest of the world and additional experience and data regarding them has been gained over the last 15 years. Today US women or their surgeons can choose either silicone or saline breast implants for whatever reason they choose.

So which is better, silicone or saline?

The answer as with many things like this depends on whom you talk to but the reality is that neither is “better”. They each have their advantages and disadvantages and it depends on the patient’s individual situation, the surgeon’s experience, and most importantly the patient’s value or importance placed on the differences to decide which implant to use in a purely cosmetic procedure. The patient should get the choice, not the government, not someone else, and not even the surgeon entirely.

The best way to understand the advantages and disadvantages of silicone and saline filled implants is that saline-filled implants have all the advantages but one big disadvantage. Silicone gel-filled implants have all the disadvantages but one big advantage. Fortunately this is not a health advantage or disadvantage. Although many accusations have been made about silicone or silicone rubber, these have not been substantiated and although there can be local complications to the breast above the implant, there is no evidence that silicone used in the human body is a threat to general health from breast implants or any other use of silicone.

Over the 13 years where saline-filled implants were the only type generally available in the US for cosmetic augmentation of the breast, many US surgeons learned how to get the best possible results using these devices and did not wait for silicone gel implants to come back on the market or find ways to get around the FDA ban. They learned how to get a result that looks just like that of a silicone gel-filled implant and found that this requires a lot more attention to detail but that saline implants have many advantages. Their disadvantage is that saline doesn’t feel like breast tissue. If they are sized properly, positioned properly, and filled properly, saline-filled implants look like gel-filled implant augmented breasts but they don’t feel like them if you can feel them. If you can’t feel them then that issue becomes unimportant.

Of course some women have breasts with thin skin, little body fat, and minimal breast tissue. Any breast implant is easy to feel. Most woman are somewhere in between a big problem of easily felt implants and those where they can’t be felt at all. Each patient is different in this regard and the answer is to show the patient where the implant can be most easily felt and tell her to what degree she will be able to feel the “ripply” or watery feel of the implant. She can then decide how important this is to her.

The other major and minor advantages of the saline-filled implant are that they can be put in through an incision as small as two centimeters (3/4 of an inch) compared to at least 4 1/2 centimeters or longer for gel implants. Saline implants cost less than half of what silicone gel implants cost and their volume can also be adjusted from one side to the other (in different size breasts) up to 10% where gel implants can’t be individually volume adjusted. The most significant advantage of the saline-filled implant is that if it fails after it is implanted, a known small risk but a definite one, it is easy to tell it has failed and arrangements can be made to get it replaced as both major US manufacturers of breast implants guarantee them for life including a reasonable amount toward the cost of the surgery to replace them.

If a saline-filled implant fails it deflates. There are no health issues or emergencies but it’s obvious that it has failed. There are no tests to run or wondering what condition it’s in. The major disadvantage of the gel-filled implant is that if it fails, and its failure rate is very similar or even less than the saline-filled implant, it doesn’t look or feel any different from the outside. Although there are no known health risks from a failed silicone-gel implant, currently there is no simple and completely accurate test to verify whether it is intact or whether it is “leaking” in media terminology. If it fails it has the same guarantee of replacement. The issue is in knowing if this has happened. We may well have better tests for verifying the integrity of silicone gel implants in the future. The best current test is an MRI which is not a simple or inexpensive test. The point is that the patient has to decide how important this issue is to her because if it’s the most important issue she can choose a saline-filled implant and not have to deal with it.

Silicone gel-filled breast implants have one advantage and it’s an important one but really it’s the only advantage. They feel like human tissue. They don’t have to be sized, positioned, or filled accurately and it doesn’t matter what the patient’s tissue cover is. So if the feel of the implant is the most important factor to the patient then she may want to choose silicone gel-filled over saline filled-implants.

The size issues and choices for saline and silicone implants are very similar with the exception of the up to 10% fill variation for saline, so it comes down to how important the patient views incision size, cost, palpability (feel), and detection of implant failure. The looks should be the same if the surgeon is experienced with either type of implant and can give the patient the choice along with the knowledge of her individual characteristics.

So the answer of which is better, saline or silicone, should be… it depends. How important are the advantages and disadvantages to you, the patient, since you’re making a cosmetic choice for yourself?

Created: 12/11/2008  -  Scott L. Replogle MD

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