Silicone or Saline?

Now that the Food and Drug Administration has reapproved the use of silicone breast implants, here’s what patients should consider before making their choices.Now that the Food and Drug Administration has reapproved the use of silicone breast imp
When Cindy Rezzano and Julie Zubek decided to increase their respective bustlines with breast implants, there were no second thoughts. The women, both in their late 30s with three children apiece, had each been thinking about the operation for years.

But when they scheduled their surgeries — Rezzano in December, Zubek in March — they were still faced with a big decision. It was one they wouldn’t have had to make just a few months earlier: saline or silicone?

Last October, the Food and Drug Administration reapproved the use of silicone implants after years of banning them for everything except breast reconstruction and the replacement of saline implants that had failed or produced unsatisfactory results. According to Beachwood plastic surgeon Dr. Steven Goldman, the data from government studies that tracked those patients refuted allegations that the implants caused problems such as breast cancer, lupus, rheumatoid arthritis and chronic fatigue.

“In every other country but the United States and Canada, they’ve not only been available but have remained more popular,” Goldman says.
Meanwhile, studies have also shown a high satisfaction with saline implants (“well over 90 percent,” he says). So which is the better choice?
“Either can produce a nice result,” Goldman explains. “The individual patient has to decide why one might be better than the other for her.”

The greatest benefit of silicone implants is the more natural look and feel provided by its viscosity, according to Goldman.
“The silicone tends to move a little bit more like natural breast tissue,” he says. Because they’re less prone to rippling, they’re often recommended for thin women with little breast tissue to camouflage them. Those two advantages were enough to convince the petite Zubek, a registered nurse, to choose silicone implants when she made her long-anticipated jump to “a very full B or small C” cup.

Her decision, however, was not made without considering the safety of her choice.

“This isn’t something that I just went into thinking, You know what? I want to have a big chest. I’ll just put whatever looks the best and lasts the longest in there,” she says. “I looked into it. I did the research.”

According to Westlake plastic surgeon Dr. Michael Wojtanowski, silicone implants have indeed improved since the controversy over them prompted an FDA ban in 1992. He explains that the old implants oozed microscopic droplets of silicone over time, even when there were no leaks in the implant covering.

“If you took a silicone gel implant, put it on a table, and let it sit there for a while, the implant would feel greasy on the surface, as would the table,” he says. The consistency of the silicone was similar to molasses. When it leaked from an actual break in the covering, it worked its way into the breast tissue, causing lumps that complicated breast exams. The silicone in the new implants, in contrast, is much more dense.

“The theory is that if these implants leak, the gel doesn’t leak out into the breast tissue as much,” Wojtanowski says.

But despite the improvements, there are still drawbacks. The new implants, Wojtanowski notes, don’t yet have a track record in the United States. Goldman adds that many plastic surgeons still say silicone implants cause a higher incidence of capsular contracture, a condition in which the layer of scar tissue that normally forms around an implant thickens and tightens up over time, causing distortion and pain.  “I’ve taken out enough old silicone implants that had a tremendous amount of inflammation around them that we know was due to the body’s trying to break down the silicone,” Goldman says. “Silicone cannot be broken down by our macrophages, or cells that take up foreign materials.”

Silicone implants are also two to three times more costly than their saline counterparts. And the expense doesn’t end after surgery. To safeguard against leaking in the long term, the FDA and silicone-implant manufacturers recommend patients schedule an exam with their plastic surgeon each year after augmentation as well as undergo an MRI at three years after surgery and every two years thereafter.

Both Goldman and Wojtanowski say most plastic surgeons do follow-up exams free of charge. The MRI, on the other hand, is a relatively pricey diagnostic test — with estimates between $1,000 and $2,000 — not covered by insurance when done to detect implant leakage. Wojtanowski recommends that women considering silicone implants check with their insurance carriers before scheduling cosmetic surgery to make sure it won’t affect their coverage.

“Some insurance companies won’t insure you at all if you have silicone implants,” he says. “Most of them will insure you with respect to everything but your breasts.”

Saline implants have never been linked with serious health problems. Therefore, no extended follow-up is necessary. If the implant ruptures, the sterile saline solution inside is simply absorbed by the body with no ill effects. And when the implant leaks, patients know it.

“It’s like a pin in a balloon,” Wojtanowski says. And, because doctors fill these types of implants once they’re placed in the body, they only require a 3/4- to 1-inch incision that can be hidden. Silicone implants, which are pre-filled by the manufacturer, require a 2-inch incision and can only be inserted under the breast, a less-desirable location for a very slender woman with so little breast tissue that there’s no crease in which to hide an incision.

The only cited negatives associated with saline implants are cosmetic. The devices are more susceptible to rippling, and many find them to be a less-natural alternative to silicone.

But both Goldman and Wojtanowski say the chances of visible rippling can be diminished by placement of the implants under the chest pectoralis major muscle. And Goldman points out that the look most of his patients desire — that of youthful, perky breasts that sit high on the chest wall and provide adequate cleavage — is more easily achieved with saline implants because “saline holds its shape better than silicone and tends not to shift downward with gravity.”

Cindy Rezzano, a surgery scheduler for Goldman’s office, chose saline implants because of health concerns and cost. For her, paying for the MRIs that are recommended for women with silicone implants simply wasn’t an option. The result, however, is everything she hoped for.
“I don’t look augmented,” she says. “My breasts don’t walk into the room before the rest of me does.”

Regardless of which implants women choose, both Goldman and Wojtanowski stress that those who undergo such surgery should plan to cover the cost of any complications associated with them.
Goldman points out that, while an insurance company may pay for treating a post-surgical infection, it may not shell out the cash to replace a leaking implant. And it’s realistic for patients to expect to need a subsequent surgery at some point in the future.

“Initially, plastic surgeons and implant companies sold [breast augmentation with implants] as a one-time procedure, and that’s just not the case,” Goldman says. “They’re man-made devices in a place that has a lot of mobility. It was not reasonable to expect these devices to last forever.”
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