If you have been contemplating breast augmentation but confused because of the large amount of confusing and sometimes wrong information, here are some straight-forward information.
Silicone vs Saline
Can’t decide between silicone versus saline? Both implants have their benefits and disadvantages. For silicone implants, the main advantage is that these implants are generally softer and feel more natural – like breast tissue. The disadvantages include: higher cost (generally about $1000 more than saline), requirement of larger incisions, questionable higher capsular constracture rates (hardening of the scar around the implant). With saline implants, the advantages include: lower cost, smaller access incisions (can be placed through smaller incisions including the belly button and armpits), and questionable lower capsular contracture rates. The disadvantages include: firmer feeling implants, increased visible rippling as compared to silicone implants. These are the obvious advantage and disadvantages of silione and saline implants. The quality of the breast tissue as well as amount of breast tissue present will also play decisive factors in determining which implant is right for you.
Cohesive Gel
There is considerable talk about “cohesive gel” implants. In the United States, the two main implant manufacturers of breast implants, Allergan (formerly Inamed) and Mentor, both use cohesive gel silicone implants. These implants are an improvement from the older silicone implants, which were more liquid in nature. Since the re-introduction of silicone implants for cosmetic breast augmentations, all silicone implants used in the United States for cosmetic breast augmentation are required to be cohesive gel by the FDA. In other words, in the United States ALL silicone breast augmentations are performed with cohesive gel implants.
What Causes Hardening of Breast Implants?
Capsular contracture (breast implant hardening), is a process where the scar tissue surrounding the breast implants become progressively thicker and harder. All breast implants form scar tissue that surrounds the implant. Most of the time, this scar is thin and soft and the augmented breast stays soft and natural feeling. Some patients form a thick scar that surrounds the implant and this process is called “capsular contracture.” This happens 10% of the time. In the past, silicone implants used to do this 20% of the time (twice as high as saline). Now with the improved silicone implants (cohesive gel), the reported rate is similar to saline implants.
What causes this problem? Currently no one knows for sure. One of the leading guesses is low grade infection. Some believe that there might have been a very low grade infection, which caused some inflamation (without pain or fever) that caused increased scarring. Another guess is bleeding. Some believe that blood surrounding the implant causes inflamation, which leads to extra scarring. Others believe that the body in some instances just heals this way. A new theory is “cotton lint.” The newest finding is that cotton lint from the sterile towels and sponges may get stuck on the implant and causes a foreign body reaction/inflamation and extra scarring. With these things in mind, breast augmentations are performed with as little bleeding as possible, with strick sterile tehniques adhered to and now in a “cotton lint” reduced environment. The implants are kept sterile, contact with patients skin is avoided, contact with cotton material is avoided.
Once capsular contracture occurs, the treatment is removal of the implant and all scar tissue surrounding the implant. A patient that has had capsular contracture is at a higher risk for this happening again. There are one set of implants called “textured” implants that have a much lower incidence of capsular contracture (2%). These implants have a rough surface, instead of being smooth. The downside to these implants are that they are not as soft as the smooth implants.
Over Vs Under Muscle
Most surgeons prefer to place implants under the pectoralis muscle (chest muscle). The pectoralis muscle covers the upper half of the chest and placing the implants under this muscle provides extra coverage of the implant. As the muscle only covers the upper half of the chest, the muscle provides coverage over the upper half of the implant. As most Asian women are thin and have a small amounts of breast tissue, the issue of providing tissue covergae over the implants becomes very important. If you place a breast implant over the muscle on a thin Asian patient, then the implant will be visibly apparent on the upper half of the chest, where naturally most patients are thinner (most of the breast tissue lies on the lower half of the chest). This becomes more of an issue, if a patient decides to loose weight. Then the tissue over the upper half of the chest will become thinner and the implants will become more visible. This could lead to issues with visibility, rippling and asymmetry. Why place them over the muscle you ask? For one, the procedure is actually easier to perform. Two, for patients who have extremely large pectoralis muscles (like body builders, weightlifters), the large muscle can flatten the appearance of the implants and thus the implants look better over the muscle. Three, per volume, implants over the muscle will fill the breast more than implants under the muscle. This is important in patients who have a very slight breast droop. By placing the implants over the muscle, the implants can give the breast more of a lift than if the implants were under the muscle.
There is also some literature/studies that report a higher capsular contracture rate (breast hardening), when implants are placed over the muscle. For patients that had previous implants where the implants became hard, the treatment would be to remove the hard capsule and the implant and replace the implant to a new position under the muscle. Some believe that the massaging effect of the muscle on the implant help to reduce the rate of capsular contracture (breast hardening).
I believe that the decision to place the implants under or over the muscle should be based on each individual. To place implants over the muscle on all patients, especially Asian patients, is a mistake. This said, I prefer to place the implants under the muscle on most Asian patients.
Dr Steve S. Kim, M.D.,PhD. is a Board Certifed Plastic Surgeon. His practice “SK Plastic Surgery” is located in Beverly Hills.
For more information or to request a consultation, contact 310-553-5315 and ask for Lauren or email info@skplasticsurgery.com