Antonio M. Carbonell, MD (retired)

Great question Pamela. As you can see from the many responses there's an overall consensus about the stability and durability of both the saline and gel implants. Anything man/woman/machine made has a potential for failure, since nothing in our body remains stable for very long.

The implant replacement issue was very prevalent during the early years of breast augmentation and before the newer 'models' were redesigned after the 10 yr moratorium by the FDA. Back then we had thin walled incompletely polymerized gel implants, sometimes enclosed in another implant of saline (the double lumen implant) and both had the problem of capsular contracture. Since we didn't know what was causing the contracture, we assumed it was silicone, and the implant was often removed with the capsule. Those were the years when multiple types of synthetics were used and multiple surfaces applied to the implants including Dacron patches to keep them from 'moving around' - a concept borrowed from hip replacement prosthesis - not exactly applicable to breast 'natural' function.

Today, with the advent of endoscopic breast augmentations and thicker implant shells, cohesive (better polymerized) gels the intrinsic problems contributed by the implant are much less. A recent disclosure that cotton (one of the most reactive of substances within the body) may be the main culprit in capsular contracture has led many of us to dispense with using any cotton gauze within the wounds, to dry any fluid drainage or use as dissecting tool (as we were taught in years past) and the capsular contracture issue is much less (from 20% to less than 0.5%) than it used to be, and implants are not removed as often.

I am starting to see patients that have had submuscular implants with several muscle induced deformities come to the realization that a submammary gel implant can give them a more natural cleavage with less 'folding' 'creasing or rippling' and enhance the overall breast texture than it ever was with saline, especially if the implant pocket was small to begin with, so I'm removing saline implants and replacing them with gels and improving the patient's overall satisfaction with their breasts.

I suspect that when the current trend of submuscular placements begins its reversal as it did 20 yrs ago when we had to use the pectoralis muscle in breast reconstruction and became disillussioned with the abnormal movement and lack of cleavage, we will see more women ask for cleavage and texture, bounce and giggle than they had in the past. The best way to achieve that will be with submammary gels and a resurgence of primary gel augmentations will occur. Time will tell.

Ultimately it's the woman who has grown accustomed to her implants as her own breasts that will decide what happens. The body image incorporation is so strong as to produce the same emotional effect as a mastectomy when an implant deflates. The idea of 'having to go through that again' will ultimately determine the decision to reach for the non-deflatable gels and get on with their lives.

I hope this helps.

Dr."C"

Dear Beaches2961,

I'm writing to endorse the excellent comments on your question. I do think that Dr. Rand hit the nail on the head when refering to the age of a tummy tuck as affecting the recovery. My 60+ tummy tucks seem to want faster recovery and notice more subtle changes than my 30+ tummy tucks do. I don't know if this is entirely age related but consider this:

You've lived with your body shape for a long time and your ligaments and muscles are used to a certain function and shape. Your skin has become less elastic and any attempt to 'tighten' it as it was when you were 17 will result in wound healing problems, like wound edge separation, delayed healing etc.

There is a very frequent loss of sensation after a tummy tuck that leads the brain into thinking 'things are bigger, fuller or tighter' than normal (much like when the dentist numbs your mouth making it feel like it's 4x its normal size). Sensory recovery (the rate of nerve function restoration) slows down as we get older, thus these 'feelings' will remain around much longer in the older than in the younger crowd.

This lack of feeling is compounded by normal tissue swelling (interstitial edema) that 'peaks' at about 6-8 weeks and starts to lessen with time. Because of this swelling, my patients love the Lipoinabox garments, which they wear up to 12 weeks 'because they feel so good', specially when they return to exercising... check them out.

Under these conditions, patience is a virtue, but so is Vitamin E, massage, swimming, pilates exercises, whirlpool and hot sauna, surface moisturizing lotions containing aloe, cocoa/shea butter etc.

The worst is behind you, enjoy what's coming up! Happy New Year!

Dr. C

Dear Leiav,

My first reaction is that with the planned surgery you're limiting both your arms and your abdomen and to a slight degree your legs from behaving normally. Add lifting a 7 month old in and out of a crib and you're adding significant strain to your incisions and run a higher risk of complications, like wound dehiscence, hematoma or fluid buildup while prolonging your overall recovery.

I used to do a lot of multiple procedures like you describe and have since become more conservative, limiting the number of procedures performed at the same time to one or two depending on the patient's recovery environment and job circumstances.

Remember this. The human body heals at a specific rate (6 weeks normally, longer in diabetics) which science has not been able to alter much, except when we add too many procedures at once, at which point, we're slowing the healing rate overall - like sending troops to fight in Iraq, Afghanistan and North Korea at the same time...

The problem is the natural 'stress' reaction within the body - which slows healing overall. The more areas, the greater the internal stress. The more external stress (caring for a baby), the slower the healing. Combine the two and you have a recipe for problems, which can prolong your recovery and return to normalcy.

Consider discussing this further with your surgeon as to why s/he is suggesting to do all the procedures at the same time, and is it possible that the procedures be staggered 6 - 12 weeks apart?

Dr. C

Dear Cherabine:

I agree with Drs. Rand and Goldstein for most patients who have a significant drift of the breast complex (including the nipple/areolar complex - NAC) over the implant. Sometimes the appearance of drift may be from a subtle capsular contracture which has elevated the implant above the NAC giving it the 'snoopy' look.

Interestingly, this effect is the principle behind the 'internal mastopexy' which leaves no external scars, and is a type of 'gathering' or 'plication' of the central and superior portion of the internal capsule towards the collar bone with a purse-string suture providing a mild 1 - 2 cm 'lift' of the NAC.

I had a patient with a 20 yr textured saline implant that 'didn't move' even though it was above the muscle, and her NAC had drifted below the central mound Dr. Rand refers to. All I had to do is re-dissect the anterior portion of the capsule surrounding the prosthesis to 'recreate' the pocket, place the pursestring sutures and add the new smooth cohesive gel prosthesis - she was a different woman in less than 2 hrs!

When you combine this subtle 'lift' with a slight lowering of the inframmamary crease (IMC) and a slightly wider, low profile, smooth surface, new gel implant design you can maintain your current texture while 're-aligning' your breasts to a more youthful position for years to come - without any new scars!

Dr. C