Answers to Frequently Asked Questions
about breast enlargement:

What are the pros and cons of silicone gel fill vs saline fill?

The implant lifespan, that is the time until failure, is the same for silicone-fill as for saline-fill. The major differences concern the eventual failure of the implants:

• How to tell when the implant has failed.
Saline:
• The failure is obvious to the woman, as the size decreases.
• No special testing such as ultrasound or MRI is needed.
Silicone:
• The failure is undetectable to the woman, as the size does not change.
• Special testing, such as ultrasound or MRI, is required.
• How to get the failed implant out.
Saline:
• A tiny incision is enough, because the capsule stays in place.
• A new saline implant can be placed through that tiny incision.
• A new silicone implant requires a larger incision.
Silicone:
• A fairly large incision is needed, because the capsule needs removal.
• The new implant can be saline or silicone.
• How quickly the operation should be performed.
Saline:
• If replacement is done within two weeks, it is a very simple operation, done through a tiny incision.
• If replacement is delayed beyond two weeks, the scar capsule probably has to be removed, which makes the operation just as large as that needed for silicone.
Silicone:
• The scar capsule usually has to be removed, which makes the operation a fairly large one.
• The FDA recommends that replacement of a failed silicone implant be done promptly.

Some patients want to know right away when their implants fail so that they can get them replaced promptly. With saline, they will know right away as the breast gets smaller, and there is no need for special tests to be done. So those patients would say the advantage goes to saline. Other patients do not want a leak to produce a noticeable decrease in their breast size, and do not want anyone else to be able to tell. So those patients would say that the advantage goes to silicone gel. Our patients who do acting or modelling, for example, could find their career impacted negatively if they experienced a size change while on a shoot in a remote location, so many of them prefer silicone-gel fill. The other side of that issue is: how can failure of a silicone-gel-filled implant be detected if there is no size change? Special testing can be done as follows.

Failure of a silicone-gel-filled implant can only be detected by doing special testing:
Accuracy of different special tests for silicone gel implant failure:
. Physical examination is less than 10% accurate.
. Mammography is less than 50% accurate.
. MRI is about 95% accurate, but costs $2500-$3000 each time. FDA recommends MRI every 2 years.
. Ultrasound is up to 98% accurate if done by an expert ultrasonographer.
. Operative endoscopy is nearly 100% accurate.
Note that complete ruptures are easier to diagnose, small leaks are harder to detect.

Then there is the question of what kind of operation is needed to replace a failed implant of each type. If done within two weeks of a leak, a replacement is fairly simple for the patient to go through for saline implants: The major part of the original enlargement operation was the formation of a pocket for the implant where there was no pocket before. So if a saline implant fails, the pocket is already there, and all that is needed is to slip the old deflated saline implant out of the pocket, and slide the new one in, through a tiny incision. Usually the same incision site is used, including through the navel. It must be pointed out that so far there is no way to put silicone gel implants in through the navel.

Replacing a failed silicone implant is usually a much more involved procedure. In that case, there are usually tiny silicone droplets within the scar capsule, and most plastic surgeons agree that removal of the scar capsule is adviseable in this situation. And so that requires a longer incision, and more time in the operating room, thus greater expense.

There is also the issue of cost. The silicone implants themselves cost more than saline implants. The surgery to insert silicone implants costs slightly more than for saline implants. Offsetting those costs a little is the fact that the extended warranty is provided free with silicone implants. An important cost consideration with silicone gel implants is the matter of the MRIs. The FDA recommends that every patient who gets silicone implants go for frequent MRIs (at her own expense about $2500-$3000) at 3 years after surgery then every 2 years thereafter. Most women say they intend to get these studies performed on schedule because it is important to them to know if their implants are no longer intact. On the other hand, we do have patients who have shared with us that they have no intention of following the FDA recommendations since there is no FDA penalty for not complying. It is entirely patient choice.

On the other hand, some women prefer the way that silicone implants feel to the touch. It is difficult to put the differences into words, but the best terms women have used are that the silicone implants feel "squishier" or more "doughy" than saline. A little experiment that can be done at home to sort of simulate the two is as follows: take two baggies; fill one halfway with water, and the other halfway with honey; remove the air from each and seal them; hold them such that the bags are fairly tight; then press a finger into the side to indent the bag and pull back the finger quickly. The difference sort of simulates the way that the implants feel when compressed. Usually it is extremely difficult to tell by squeezing the breast whether the implants are saline or silicone. Similarly, it is generally not possible to tell by appearance or photos whether the implants are silicone or saline.

As far as hardening of the scar tissue capsule is concerned, the chance of such capsular contracture is higher with silicone than saline: about 5% chance with saline, and about 15% chance with silicone.

Many plastic surgeons strongly prefer silicone implants over saline implants, and it is not just because silicone implant surgery is much more expensive, as some people have suggested. The reason for the surgeons' preference has to do with avoiding disruption of the surgeons' practice schedules. When silicone implants fail, there is no great hurry to replace the implants, because the size does not change, therefore the scar pocket remains full size. The silicone replacement operation can be scheduled for a future date that is convenient for the surgeon (and the patient of course). But when a saline implant fails, the scar pocket starts contracting very soon. If the saline replacement procedure is to be simple, inexpensive, and fairly painless, it must be done promptly (usually within two weeks) and that creates a major problem for the surgeon. The operation has to be added-on to the surgeon's schedule on short notice, preparations made quickly, new implants ordered, etc, all of which is very disruptive to the surgeon's schedule. So many plastic surgeons prefer silicone implants.

Which is better? It should be clear that both saline and silicone are excellent choices, but just different from each other. Both result in happy patients who are glad they chose to have the operation done!

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