“Are silicone implants better than saline implants?”

Since the 2006 FDA approval for silicone implants to be used in breast augmentation, I have received several emails a week inquiring whether silicone implants are better than saline implants.  Lately, my patients have been asking this question almost every day.   I feel part of this is due to recent marketing campaigns being conducted by the major breast implant manufacturers in the United States.  Silicone is all the rage.  Right? 

First, I’d like to respond to this question by saying that both types of implants have benefits and trade-offs.  As a board certified Plastic Surgeon, I feel that I am obligated to educate and inform my patients about their options. 

In the plus column for silicone implants:  There is little doubt that the texture of the gel more closely mimics breast tissue than saline does.  Also for patients who are extremely thin or who have little breast tissue, rippling and wrinkling can be less of an issue with gel implants than with saline implants.   Lastly, the satisfaction rates for silicone implants are very high and approach 97% in some studies. 

In the negative column:  Silicone implants are more costly in both the short and long term to patients.  At the time of surgery, the devices are approximately twice the cost of saline implants and this cost is translated into a patient’s quote for surgery.  Over the subsequent years, breast MRIs are currently recommended to monitor for silicone implant rupture.  Under the current guidelines, this study is to be performed at 3 years after surgery and then every 2 years thereafter.  Patients should understand that this study is very costly and not likely to be covered by insurers.  Very quickly, the cost of repeated MRIs will exceed the cost of the initial surgery.   Also silicone implants come prefilled and due to this require incisions that are twice as large to place them.  This impacts recovery times and scarring.  Furthermore, patients need to understand that breast implants don’t last forever and very often they will need to be replaced in the future due to rupture.  Silicone implants can complicate these future surgeries.  Lastly, the capsular contracture rate associated with silicone implants should be considered.  A capsule is a scar that develops around an implant on the inside of the breast.  This scar can shorten or contract over time causing firmness in the breast, change of breast shape, or pain.  The historical rates for capsular contracture at 10 years is on the order of 38.5-90% for silicone implants.  Saline implants have a 10 year capsular contracture rate of 16.6%. 

So to answer the question, “Are silicone implants better than saline implants?”  It depends.  Blanket statements by the public, surgeons, or manufacturers can not be made.  The individual needs of a patient will make this determination.  One woman may decide that the feel of the silicone implant in comparison to a saline implant makes it better for her, and with this, she is willing to accept certain tradeoffs.   Another woman may decide that the benefits of saline implants in terms of capsular contracture outweigh the feel of her implant.  I truly believe that a patient who is fully informed about her options will choose the best implant for herself, be it silicone or saline. 

Here is an example of a patient that underwent a silicone breast augmentation in my practice.  She is a 26 y/o woman that presented desiring silicone breast implants.  She was very concerned about the feel of her breasts after surgery and wished to have an augmentation that would closely mimic the natural feel of her breasts.  On examination, she has some mild asymmetries and only fair soft tissue coverage.  Here is the preoperative photograph:

During our consultation, she expressed that she would like to have a large augmentation.  She decided that she would like to use 500 cc silicone implants.  Due to her soft tissue characteristics and due to her desire for a silicone implant, I recommended that she undergo a dual plane breast augmentation through an inframammary (breast fold) approach.  Here is the postoperative result:

The operation achieved her goal of a large breast augmentation with implants that feel very natural. 

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information about breast augmentation and before and after photographs for review.  I invite you to schedule a consultation with me if you would like to learn more about silicone implants or breast augmentation.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

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“What options are available to help the shape of my breasts?” Part 3 of an answer in 3 parts.

This is the final post regarding breast shaping options and why a woman might choose one option versus another. 

Why would a woman choose to have a breast reduction (reduction mammaplasty)?

Excessive breast development can cause significant physiological and psychological distress.  A woman may feel self conscious about the large size of her breasts and feel that they are an impediment to her ability to perform her job, exercise, or to wear certain fashions.  The weight of the enlarged breasts may cause significant neck and back pain as well as significant grooving in the shoulders from brassiere straps.  This grooving may lead to nerve compression and result in numbness of the hands.  Hygiene may be an issue with large breasts, and a woman may experience chronic skin irritation or infections in the fold of her breasts especially in the summer.  In severe cases of breast enlargement, skin ulceration can occur.  Breast enlargement may limit a woman’s ability to exercise and place her in a vicious cycle of weight gain.  These problems are improved or resolved with breast reduction surgery.  Over 90% of women surveyed following breast reduction are happy they underwent the procedure and would undergo it again.  In many instances, health insurance carriers may cover a breast reduction procedure.

Why would a woman choose to have a breast reconstruction?

Congenital deformity, or in more severe cases, complete absence of the breast may motivate a woman to seek a breast reconstruction procedure.  Alternatively, a patient who has undergone treatment of breast cancer may feel that she is missing a component of her identity.  Mastectomy without reconstruction removes the entire breast and leaves a scar on a flat bed that once had a feminine contour.  Breast conservation therapy followed by radiation can leave a woman with a contracted, disfigured breast.  These situations are painful daily reminders of a woman’s encounter with a potentially fatal disease.  Breast reconstruction is designed to help in the healing process of a woman, restore her identity, and help make her feel whole again.  Typically, reconstruction is performed in several stages that begin with the creation of a breast mound using either implants, the patient’s own tissues, or a combination of both.  Additional procedures such as a breast lift or reduction for the other breast are performed to improve the symmetry between them.  The reconstruction culminates with the reconstruction of the nipple and ultimate tattooing of the areola.  In 1998, the Women’s Health and Cancer rights Act was enacted requiring health insurance carriers to cover breast reconstruction in conjunction with mastectomy.

Our websites www.beauty-surgeon.com and www.drmckane.com have  additional information about breast contouring procedures and before and after photographs for review.  I invite you to schedule a consultation with me if you would like more information about these procedures.  Please feel free to contact our office at (713) 661-5255.

-Brice W. McKane, M.D.

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“What options are available to help the shape of my breasts?” Part 2 of an answer in 3 parts.

This is a continuation of my last post answering some questions dealing with breast shaping options and why a woman might choose one option versus another:

Why would a woman choose to have a breast augmentation? 

The most common concern that I hear from a woman considering breast augmentation (augmentation mammaplasty) is that she does not feel that her upper body is proportional with her lower body.  She may have gone through adolescence with her mother’s assurances, hoping to have more breast development than she did.  Often times, her mother or sister has what she believes to be an ideal breast size.  It is possible that a woman with small breasts  who has hypertrophy of her breasts with pregnancy and breast feeding likes the appearance of her larger breasts.  She may become disappointed with the involution she experiences when she stops breast feeding.  Breast augmentation can be considered by any woman looking to increase the size of her breasts. 

 Why would a woman choose to have a breast lift? 

Unfortunately, the soft tissues of our bodies are constantly battling gravity.  As we age, the support structures that keep these tissues in an elevated and youthful appearing position become lax and gravity begins to pull them down.  With this, we see descent of these tissues, a process that occurs in most areas of our bodies.  The breast is no exception.  With time, the breast mass and the position of the nipple areolar complex descends on the chest wall.  This is known medically as “breast ptosis.”  The upper portion of the breast will flatten as the breast mound descends and ultimately the nipple areolar complex may assume a position at the lowermost pole of the breast.  This is the natural history of breast aging.  This can also be seen in a woman who has undergone massive weight loss.  A mastopexy or “breast lift” can be performed in a woman who has breast ptosis and who would like to improve the position of her nipple areolar complex and the contour of her breasts.  if a woman wants to add volume to her breasts at the time of her breast lift procedure, this is possible using breast implants. 

In my next post, I’ll continue with my discussion about breast contouring procedures.  Our websites  www.beauty-surgeon.com and www.drmckane.com have additional information about breast contouring procedures and before and after photographs for review.  I invite you to schedule a consultation with me if you would like more information about these procedures.  Please feel free to contact our office at (713) 661-5255. 

-Brice W. McKane, M.D.

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“What options are available to help the shape of my breasts?” Part 1 of an answer in 3 parts.

I receive several emails a week inquiring about the procedures available to help breast shape and contour.  I’d like to respond to this question by delving into some of the motivations of why a woman might choose one procedure versus another.  I’ll answer in 3 parts over the next few days: 

What motivates a woman to undergo a breast contouring procedure?

The breast is the most powerful symbol of female identity.  It has been celebrated throughout time for both its ability to nurture and as an object of desire.  One can easily find classic imagery of the breast in religion, art, and literature.  Today, the power of this symbol is used aggressively in advertising.  A woman is constantly bombarded by images of young, full, healthy appearing breasts.  These images become cemented in her mind as an “ideal.”  Changes in the contour of the breast that occur with age, significant weight gain or loss, pregnancy, or cancer may move a woman away from the “ideal” breast shape that she once possessed.  By our very nature, we compare ourselves to these perceived ideals.  A woman who seeks a breast contouring procedure is dissatisfied with the appearance of her breasts and wishes to transform them closer to her ideal. 

What options are available to improve the appearance of a woman’s breasts? 

A woman can consider breast augmentation, breast lift, breast reduction, breast reconstruction or a combination of procedures depending on her goals and the specifics of her case.

In my next post, I’ll delve a little more into why a woman might choose one procedure versus another.  Our websites www.beauty-surgeon.com and www.drmckane.com have additional information about breast contouring procedures and before and after photographs for review.  I invite you to schedule a consultation with me if you would like to learn more about these procedures.  Please feel free to contact our office at (713) 661-5255 if you have any questions.  

-Brice W. McKane, M.D.

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“Is it possible to have a breast augmentation after a breast reduction at your center in Houston?”

I received an email today from  a young woman who is not happy with the size of her breasts following a breast reduction (reduction mammaplasty) procedure.  She writes, “When I was 16 I suffered from very large breasts.  I had a lot of neck, shoulder, and back pain which was improved by my reduction.  I’ve always felt that I was made too small.  Now, I’m 24 and I’m going to be married next summer.  Is it possible to have a breast augmentation after a breast reduction in your center in Houston?  I really want to look good in my wedding dress.  Please help.”

There are over 100,000 breast reductions performed in the United States each year.  The literature addresses many of the complications of this procedure but long term outcomes studies have failed to identify patients who are unhappy with their final size.  Women may experience immediate dissatisfaction if the breasts are over reduced and little breast tissue remains following the procedure.  Other women may become dissatisfied with time as changes occur in the breast due to volume loss following weight changes, pregnancy, or with age.  

A recent study by Colwell et al. identified 7 patients who felt that their breasts were too small following their breast reduction surgery.  The study shows that breast augmentation can be a useful technique in women with this problem.  All of them had an improvement in their body image scores following breast augmentation.  5 out of 6 of them were very satisfied following the procedure.  

Here is an example of a patient that underwent a breast augmentation in my practice following a breast reduction by another surgeon.  She is a 36 y/o woman who underwent a small breast reduction in 1997.  She was pleased with her surgery until recently when she has felt that her breasts have become “deflated”    On examination, she had lost upper pole fullness and volume in her breasts.  She also has pigmented scars typical of a patient with a prior history of a breast reduction.  Here is the preoperative photograph:

During our consultation, she decided that she would like to use a 325 cc implant to help restore her breast volume.  Due to her prior history of a breast reduction, I elected to put her implant into the sub pectoral plane.  I used a small segment of the breast fold incision that she already had as the approach.  Here is the postoperative result:

The operation achieved her goal of a fuller breast following breast reduction surgery.    It should be noted that this patient also underwent a tummy tuck (abdominoplasty).

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information about breast augmentation and before and after photographs for review.  I invite you to schedule a consultation with me if you would like to learn more about this procedure.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

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“What is a dual plane breast augmentation?”

I have received an email today from a nurse considering breast augmentation.  She writes…”I have recently become aware of a new position for breast implants.  I understand what subglandular and submuscular breast augmentations are.  Would you explain to me what a dual plane breast augmentation is?”

There are several sites that implants can be positioned in the breast.  I’ll review them all for you:

Subglandular - is a site where the implant is positioned immediately behind the breast gland and in front of the pectoralis muscle.  This is a reasonable position for patients that have a fair amount of breast tissue.  The greatest benefit for it is that patients generally have a faster recovery period and it can be beneficial for some types of breast shape.  If a women is active, this position is not associated with any significant breast distortion with pectoralis contraction.  One downside of this site is that there is increased implant visibility and the breast has a more augmented appearance.  Other downsides include probable increased risk of capsular contracture (firm breast formation), and greater interference with mammography and breast cancer detection. 

Subfascial - A fascial layer is a sheet of connective tissue that binds together or separates muscles.  An implant can be placed beneath the fascial layer of the pectoralis muscle.  This position in theory has some of the benefits of each of the more common positions – subglandular and subpectoral.  It has some ability to provide more coverage for an implant and make it less visible than the subglandular plane.  The problem is that the pectoralis fascia is a very thin structure in some patients and may be less than 1/2 of a millimeter in thickness.  In this type of patient, the benefit of using the subfascial plane remains to be seen and further study will need to be conducted before we have a definitive answer.

Subpectoral- This site usually means partial muscle coverage of the implant by the pectoralis muscle.  Due to the anatomy of the muscle and the nature of the dissection, the upper portion of the implant is covered by the muscle and the lower portion is behind the breast gland.  This site generally has better upper pole breast contour as the muscle serves to soften the transition between the breast and the implant.  This position also has a lower rate of capsular contracture associated with it and improved visualization of the breast on mammograms.  The downside of this position is that it generally requires a longer recovery period, and it may cause an increased risk of a double bubble deformity in patients with specific breast types. 

Total submuscular- total coverage of the implant was used in the past to reduce the risk of capsular contracture and implant visibility.  This involved not only using the pectoralis muscle to cover the implant, but also recruited other muscle groups to assist with this as well such as the serratus muscles or in some instances the rectus muscles.  This procedure had a very lengthy recovery period and was associated the highest risk of superior implant malposition and double bubble deformities.  The lower pole of the breast and breast fold also had poor shape and definition due to the muscle’s inability to fully expand.  This position is not commonly used for primary breast augmentation, but may be used in patient undergoing breast reconstruction. 

Dual  plane- this site was originally described by Dr. Tebbetts as a variation of the subpectoral position.  It has several advantages over the previously mentioned sites and is the plane that I prefer to place implants into.  A dual plane augmentation has several variations defined by division of the pectoralis muscle along the breast fold and varying degrees of dissection in the subglandular plane.  The implant sits both behind the pectoralis muscle and behind the breast gland.  That is, it lies in two planes or the “dual plane.”  It has several advantages in that it allow for reduced visibility of the implant at the upper pole of the breast, reduced risk of capsular contracture, reduced interference with mammography, reduced muscle distortion of the implant, and decreased risk of double bubble deformity with certain breast types.  It has a similar recovery period to the subpectoral plane. 

Here is an example of a patient who underwent a dual plane breast augmentation in my practice.  She is a 30 y/o woman who presented wanting a breast augmentation.  She was a B cup and wanted to have a proportional for her frame augmentation.  She had some early descent of her right breast causing her mild breast asymmetry.  This is the preoperative view: 

During our consultation she decided to use a 325 cc saline implant.  Due to the breast asymmetry that she had and due to her concerns about implant visibility, capsular contracture, and breast cancer detection she decided that she would like to use the dual plane.  I performed one of the variations of the operation on the right side to help her asymmetry.  Here is the postoperative result:

The operation achieved her goal of a natural, proportional augmentation.  By performing the dual plane augmentation and one of its sub types on the right side, her asymmetry was improved.   

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information about breast augmentation and before and after photographs for review.  I invite you to schedule a consultation with me if you would like to learn more about dual plane breast augmentation.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

Posted in Breast Augmentation, Breast Implant Positions, Home | 1 Comment »

Are you looking for help with firm or hard breasts following breast augmentation (capsular contracture)?

As a board certified Plastic Surgeon that specializes in breast and body contouring I am often asked for advice about problems associated with cosmetic surgery.  I  received an email yesterday asking for help with breasts that have become firm and hard following breast augmentation surgery.  I’d like to comment on this here to provide other women with this common problem an avenue to find out additional information that may help them. 

The most likely diagnosis for firm breasts following breast implants is capsular contracture.  An implant capsule is a scar that forms around the implant on the inside of the breast.  Capsules develop in all women who have undergone breast augmentation.  In and of themselves,  capsules are not a problem.  The problem begins as the scar begins to shorten or contract around the implant.  In milder forms this squeezing on the implant causes breast firmness.  Unfortunately, the problem can be progressive causing very hard breasts, change in the shape of the breast,  or even pain in the breast.  In a recent study by Allergan, an implant manufacturer, the risk of developing significant capsular contracture after silicone breast augmentation is 14.8% at 6 years. 

Capsular contracture, at least in theory,  is reduced when implants are positioned behind the pectoralis muscle, when implants are massaged daily to stretch the implant capsules, and by the use of textured implants.  That being said, capsules can still develop even when all of these options are exercised.  Some patients may have a predisposition to developing exuberant scars.  Others may develop a collection of blood around their implants (hematoma) or an infection that can contribute to the development of the problem. 

There is research being conducted into the use of medications to prevent and treat capsular contracture.  Accolate(Zafirlukast) a leukotriene antagonist used initially for reactive airway disease showed promising results in reducing breast firmness over a 6 month treatment course.  More recently, Pirfenidone, an antifibrotic medication prevented the development of capsular contracture in an animal model.  Both of these medications will need additional study before being used widely in the treatment of capsular contracture.

The mainstay of treatment at this point for capsular contracture is surgery.  Implant capsules can be opened up in a procedure called capsulotomy, or they can be removed in a procedure called capsulectomy.  Implants are typically  exchanged at that time.  Some women may elect to have their implants removed and not replaced.  If this is the case, additional breast contouring procedures such as breast lift (mastopexy) may be necessary.   

I have included a case presentation that demonstrates the typical findings of this problem.  She is a 49 y/o woman who underwent a subglandular silicone breast augmentation in 1988.  Over time, her breasts have become ”rock hard” and are now causing her pain.  These are the preoperative views of the patient showing distortion of the breast and firmness in the upper portions on both sides.  Examination of the breast demonstrated extremely firm breasts with probable calcification of her capsules.  Here is the preoperative view:

The patient underwent a procedure where her breast capsules were opened (capsulotomies) and removed (capsulectomies) to restore softness to the breast.  New implants were positioned into the Dual Plane to reduce the risk of recurrence of her capsular contractures.  We spoke about performing a breast lift for her but she declined and was only interested in addressing her implant capsules.  These are the postoperative views at 6 months:

The surgery achieved her goals of a much improved and natural slope of the upper portion of the breasts.  The breasts are completely soft and no capsule is palpable by examination.   

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs for review.  I invite you to schedule a consultation with me if you are experiencing this problem and are looking to learn more about this common problem.  Please feel free to contact our office at (713) 661-5255 if you have any questions. 

-Brice W. McKane, M.D.

Posted in Breast Augmentation, Correcting Problems with Breast Implants, Home | No Comments »