What's the differences between the types of implants?
Doctor Answers 5
Types of implants
Since the material inside breast implants is what gives them their “feel,” choice of filler material has generated much controversy and media interest, not to mention scientific debate. We can provide both the science and years of expertise to help you determine whether saline or silicone is best for you.
Until 2012, only two companies produced breast implants FDA-approved for use in the United States (Mentor Corp., now part of Johnson and Johnson; and Inamed Corp., previously McGhan Medical, now owned by Allergan, Inc.). For the first time in 20 years in the United States, a third company (Silimed) received FDA approval on March 9, 2012 to sell their Sientra brand of silicone breast implants, including textured anatomic silicone gel implants.
Prior to the FDA restrictions of 1991-1992, numerous companies produced breast implants with different designs, surfaces, and filler materials, including polyurethane-coated silicone gel implants, silicone-saline double-lumen implants (the Becker implant), and PVP hydrogel filled implants designed to pass mammography X-rays and have a feel more like silicone than saline (the Bioplasty Misti-Gold implant). After the FDA restrictions, these implant options and companies were lost to USA patients, though some of these companies and options remain available in other countries.
In the United States, besides the presently-available Mentor, Allergan, and now Sientra implants, several companies have produced other types of implants such as Hutchison saline implants, Ideal saline implants, and others. As of January, 2016, the Ideal implant has received FDA approval, but other investigational implants are not yet FDA-approved and are being implanted only by plastic surgeons associated with the FDA investigation/approval study process.
Silicone or saline? (How about fat?)
Many plastic surgeons offer both saline and silicone breast implants.
Nationally, 85% of women choose silicone. Many plastic surgeons still encourage the use of saline implants, though not because they have been proven to be safer or have some beneficial effect regarding connective tissue or autoimmune disorders (the science about that will be discussed below). More commonly it is because saline implants are less costly (higher profit), easier to insert (rolled up and then filled inside the body), can be used via armpit or belly button incisions, and leave slightly smaller scars—NOT because they are better or feel more natural!
With nearly 3 decades of experience with fat grafting, we do this procedure for many locations throughout the body, but do not recommend fat grafts for elective breast augmentation in normal breasts.
Saline identical to intravenous fluid was the most common type of breast implant filler material used in the United States from 1992 until November 2006, when the FDA re-approved the use of silicone gel-filled implants for primary elective breast augmentation. Prior to the 1992 FDA restrictions, silicone gel implants were utilized in over 85% of all breast augmentations in this country, and remain the most commonly used implants worldwide.
Unusual Filler Materials Other types of filler material for breast enlargement have been evaluated over the years, and one or more problems are associated with each of these. Ivory balls, paraffin wax, sponges, and other unusual materials were used in historical efforts to surgically enlarge breasts; results were dismal until silicone came into use in the 1960’s. More recently, with the FDA silicone restrictions of 1992-2006, soybean oil-filled implants were studied extensively, and were used in many patients in Europe, as well as a few US patients in FDA studies. Breakdown of the oil, rancid smell, and other concerns ultimately led to withdrawal of this implant (Trilucent™) in the US and in Europe. Fat as implant fill material has the same concern, and is not used.
Fat Grafting for Breast Enlargement Fat graft injections of a patient's own liposuction fat (directly into or beneath the breasts) have been performed by some physicians. Among other names, this has been termed “natural breast augmentation” since enlargement is achieved by using a woman’s own fat tissue (but you also have to pay for the liposuction used to obtain the fat)! Most doctors performing fat graft breast augmentation admit that they can achieve no more than ½ to one bra cup size enlargement (which interestingly, is the same size increase stated for Brava suction cup enlargement, which has now been “recycled” as a fat-grafting “preparation to increase vascularity” and boost “take”). The American College of Surgeons and the American Society of Plastic Surgeons are not yet endorsing breast augmentation via fat grafting because a portion of the transferred fat always dies (30-50%), and can cause microcalcifications and scar tissue lumps within the breast that can interfere with both breast examination and the mammographic detection of breast cancer.
Though many radiologists state that they can tell the difference between dead-fat microcalcifications (from fat grafting) and dead-fat microcalcifications (from possible breast cancer), the majority of plastic surgeons (including Dr. Tholen) are not willing to risk your life for an unproven procedure, especially as 1 in 8 or 9 women will develop breast cancer in her lifetime. And also, since implants are still a superior choice lacking these mammographic concerns.
Scientific studies confirm that fat cells removed via “standard” liposuction are mostly destroyed and non-living; improper storage of the fat for later use (freezing) kills even more cells (ice crystals puncturing cell walls kill the fat cells), so this is worthless and potentially harmful. The same goes for fat harvested with SmartLipo (laser destroys the living fat cells) or excessive ultrasonic liposuction (too-much ultrasonic energy ruptures the living fat cells). Dead fat cannot turn into living grafts that maintain volume. Unless your surgeon uses appropriate fat harvest technique, and transplants the still-living fat globules in carefully-spaced tunnels with the tiny fat grafts surrounded by abundant healthy tissue for blood supply, the transplanted fat is not going to survive. Any breast enlargement thus achieved is gradually and ultimately lost as the dead fat is absorbed and carried away by the body—potentially leaving scars, lumps, and calcifications.
Breasts augmented with fat grafts that die, calcify, or become scarred nodules within the breast are far from “natural.” And as the dead cells are removed by the woman’s body, the once-larger breasts gradually lose size. Many former fat graft breast patients return for the implants they should have had in the first place.
The latest marketing “hype” around fat grafting for breast enlargement uses the term “stem cell breast augmentation.” This is the same procedure as fat grafting, but with the possible addition of centrifugation or addition of blood plasma to “concentrate” or “enrich” the “stem cells.” Until peer-reviewed scientific research validates fat grafting (or the even more “out-there” stem-cell breast enlargement), this should be considered experimental only!
Saline Implants Between 1992 and 2006, FDA restrictions on the use of silicone gel implants for elective, first-time breast augmentation meant that most women received saline-filled silicone-shell implants. Minneapolis Plastic Surgery has many satisfied patients with saline-filled implants who underwent their breast augmentation during these years, and many are shown in our website photo gallery mpsmn.com. Because of our significant numbers of patients who received them during this period, we also became well-aware of the pros and cons of saline-filled implants.
Numerous scientific studies were performed during these years of implant controversy, and to date, there has not been one credible peer-reviewed study that shows cause-and-effect relationship between silicone gel or saline implants and any sort of auto-immune disease or illness. Saline implants can leak and deflate, particularly if they are not filled properly, and they have also been shown to have a higher visibility of rippling or wrinkling on the implant surface. This rippling is often unsightly and unnatural in appearance, and tends to be worse when bending over or when wearing swimsuits or cleavage-revealing clothing. Implant placement below the pectoralis major muscles reduces saline-implant ripples, and usually eliminates them when silicone gel implants are used.
Saline implants cost less, and can be inserted via a slightly shorter incision, though we continue to be surprised by the length and placement of breast augmentation incisions (both saline and silicone) in patients we see from other surgeons. Incision length is much less a factor of saline vs. silicone than choice of surgeon. We have also found that the cost differential between saline and silicone gel implants is not always passed on to the patient, making saline implants more profitable than silicone in some doctors’ offices, and perhaps skewing why they may make a certain implant recommendation.
Surgeons who tend to promote the use of saline implants may do so out of training, their own experiences, habit, or profit motive, but those who scare patients with (disproven) autoimmune illness association, or tell them of the (outdated) FDA recommendation for every-other-year MRI scans in silicone implant patients (unnecessary for the latest generation of cohesive silicone gel implants), only serve their own interests, not those of their patients. These are old, outdated, and inapplicable “concerns” that have been exhaustively studied and no longer apply. Strongly-held and science-based facts are fine; “scare tactics” designed to coerce thinking to a particular point of view (or implant) are not.
Leak and deflation of saline implants require surgical replacement (the implant manufacturers provide free lifetime implant replacement, and will cover a majority of the surgical costs for the first ten years after initial implantation). But another operation is needed, including time off from work or social activities, and restrictions during healing. When saline implant leak requires re-operation, a majority of my patients choose cohesive silicone gel implants to replace both of their saline ones, ensuring that leak and deflation can never again occur. Significant numbers of my patients who initially received saline breast implants have undergone a second procedure (whether they had a leak or not) to replace their saline implants with the latest generation of cohesive silicone gel implants. Rippling is eliminated or significantly reduced, softness and natural “feel” is enhanced, and leak or deflation is no longer a concern. Many also used this opportunity to choose a different (usually larger) size. Whatever the reason, and despite the fact that many happy saline implant patients remain without concerns and with excellent results, a majority of my patients now choose silicone gel implants.
Silicone Implants The newest generation of cohesive silicone breast implants provides incredibly natural-looking and feeling results, and also a high level of safety. Previous versions of silicone gel implants had thin shells and liquid or oily silicone filler, were extremely soft, and were susceptible to rupture, leakage, or microscopic silicone “bleed.” The latest types of silicone gel breast implants (by any of the 3 USA implant manufacturers) have been used as part of the more general FDA study since 1992, and are soft, yet still a cohesive solid gel that cannot leak. These implants do not leak even if the shell is cut or punctured, and these implants can still be inserted via a 1½-inch incision. Slicing open one of this latest generation of breast implants is like cutting Jell-O—you get two solid intact parts and leakage does not occur. (These implants are often erroneously called “gummy bear” implants since they are cohesive, though the true first “gummy bear” implants were the Allergan style 410s.)
Allergan style 410 implants are made with a more firm (“highly cohesive”) silicone gel that is described as “form-stable,” meaning its teardrop shape is maintained in the body (even when reclining). Because proper orientation is critical for normal breast appearance (upside-down would look mighty strange, for example), the surface of this implant style is textured to adhere to the surrounding tissues. This highly-cohesive, firm silicone gel material led to the lay description “gummy bear” implant. Like all cohesive implants, this “highly-cohesive” implant retains its form and innate integrity even when its outer shell is punctured. This implant is more firm (like a “gummy bear” or silicone bathtub seal) than the softer, latest-generation, cohesive silicone gel implants, and requires a larger 2.5 inch incision for placement. (It’s also more costly.) This implant—Allergan (formerly McGhan) style 410—has now been FDA approved, but we feel this implant configuration (form-stable, highly cohesive, textured, teardrop-shaped) is usually more appropriate for reconstructive or “rescue” operations than for primary cosmetic breast augmentation.
Now that a third implant manufacturer (Silimed) is producing Sientra implants that are FDA-approved for use in this country, additional options exist for patient and surgeon choice. Sientra has decided to sell their products only to American Board of Plastic Surgery-certified plastic surgeons (a laudable position), whereas Mentor and Allergan will sell their implants to any licensed physician, regardless of specialty. (This is how Dermatologists, Family Practitioners, and doctors with little or no plastic surgical training can legally obtain breast implants, and insert them into unwitting patients who think that their “cosmetic surgeons” have the same training and certification as ABPS-certified plastic surgeons.) Whether or not Sientra’s “plastic surgeons-only” policy will confer better statistics, outcome studies, or lower complication rates than the other companies’ practices remains to be seen. I’d bet on it; and I’d also bet that the company will use that data to sell more implants. But what that anticipated data will really tell us is that implants placed by American Board of Plastic Surgery-certified plastic surgeons are going to have a far lower complication rate than implants placed by non-plastic surgeons.
Sientra also was the first company to receive FDA approval for their own brand of “high-strength” cohesive, textured-surface, teardrop-shaped (form stable) silicone gel implants, as their approval pre-dated Allergan’s style 410 FDA approval. They also began marketing all of their cohesive implants as “gummy bear implants.” This confused individuals who used the “gummy bear” moniker to describe the Allergan Style 410 textured cohesive teardrop-shaped implants. For this reason, I personally believe that although the term “gummy bear” is descriptive and “catchy” to use, it has now become confusing, since each implant manufacturer has its own version of textured-surface, shaped, cohesive, “high-strength,” or “highly cohesive” silicone gel implants. Plus, the “regular” smooth round silicone implants are also cohesive. So they’re ALL “gummy bears” and they’re NOT all “gummy bears,” depending on how you define the term.
Bottom line: all silicone gel implants by all implant manufacturers are cohesive, whether they are round or shaped, textured-surface or smooth, so none can “leak.” Rupture, though possible, is extremely rare unless the implant is damaged during insertion. This is why I feel MRI is not useful as a screening tool.
With silicone gel or saline implants, microscopic silicone molecules can still enter a patient's body, just as liquid silicone does in the patient who has an injection with a needle lubricated with liquid silicone. No scientific study to date has provided credible evidence that silicone has any cause-and-effect relationship with autoimmune diseases or conditions such as rheumatoid arthritis, lupus, scleroderma, or so-called "human adjuvant illnesses." With these studies in mind, silicone gel breast implants were FDA-approved in November 2006 for elective first-time cosmetic breast enlargement in women over the age of 22. Use of silicone gel implants in women under age 22 is considered “off-label” use and is perfectly legal. I support the right of properly-informed women between the ages of 18 and 22 to consent and request the implants of their choice, including silicone gel implants.
The present generation of cohesive silicone gel implants made by Allergan Corporation are called Natrelle implants, and we now offer the newest Natrelle Inspira cohesive silicone gel implants. These are identical to the previous Natrelle implants, but with additional gel “fill” in the silicone shell, about 95% vs. 85%. I believe these implants have the same degree of softness but with even less potential for visible rippling in extremely thin patients with very little breast tissue to “cover and conceal” any implant edge or ripple. I now use the Inspira implants in the majority of my patients who request silicone implants.
Is an MRI really necessary every two years with silicone implants? If your silicone implants were produced before the FDA restrictions of 1992, they were previous-generation devices that had a thinner shell and a less-cohesive gel filler. In other words, if an implant was damaged or defective, the silicone gel could indeed “leak” into surrounding tissues, eventually causing scar formation and capsular contracture. MRI studies proved to be more effective at detecting these kinds of implant damage and leak than physician exam, leading to this “recommendation” from the FDA.
However, since all 3 USA breast implant manufacturers now make cohesive or highly cohesive silicone gel implants, “leakage” does not occur, and since the shells are thicker and much more durable, implant rupture from manufacturers’ defect is extremely rare, and surgeon damage during insertion is the most common cause of implant “rupture.” Use of the Keller Funnel decreases forces on implants during insertion, and taking care to avoid contact with needles, instruments, or other sources of implant damage can virtually eliminate rupture. Since present-day solid cohesive silicone gel implants (from all 3 manufacturers) cannot “leak,” many plastic surgeons, including myself, do not believe there is any value in MRI evaluation of asymptomatic breast implant patients. In fact, there is also a “false positive” rate of 21%, where absolutely normal intact implants are erroneously read as “ruptured” by MRI. I do not recommend MRI on asymptomatic patients whose breasts are soft and implants move normally.
How long do implants last? This is a common and appropriate question, since it takes an operation to replace them for any reason, including request for different size. The latest cohesive silicone gel implants (by any of the three USA manufacturers) are not intended to be lifetime devices. That being said, barring complications regarding size, position, contracture, or infection, I believe that these devices will last much longer than the majority of their human recipients. They cannot “leak,” rarely have a manufacturer’s defect or rupture (requiring extreme injuring force or surgeon damage during insertion), and if kept from becoming bacterially contaminated at the time of surgery or subsequent dental work, they do NOT require “replacement” after ten years, or usually ever. I certainly have a significantly lower re-operation rate than the 47% in 7 years quoted in some of the implant manufacturer data. But then again, that data includes doctors of any type who decide they want to place implants, even without training and certification by the American Board of Plastic Surgery—hence, the higher numbers.
Thank you for your question. The difference in implant profiles is mostly a difference in width vs projection. Basically, the higher the profile, the narrower the implant and the more it projects forward (when comparing similar sizes). In general, this will give more volume and usually a less natural look as you increase from low to moderate to high to ultra high profile. I have included a link below to a webpage with images of some of the options.
Hope this helps
Justin M Jones, MD
Different types of implants
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Differences between Breast Implantd
You can see a lot of implant photos on the manufacturer's websites but that may not educate you on how each implant may look in you. Your best bet is to find a good Plastic surgeon who offers computer 3D imaging like VECTRA by Canfield which allows a 3D image of you with every implant in the market to be viewed from every angle. This would educate you more than anything else on what implant would be best for you.
Dr. Peter A. Aldea
What's the differences between the types of implants?
I prefer to have a wide selection of implants (all profiles) available in the operating room. I use intraoperative sizers and place the patient in the upright position to evaluate breast size. Use of these sizers also allow me to select the breast implant profile (low, moderate, moderate plus, high-profile) that would most likely achieve the patient's goals. The patient's goal pictures are hanging on the wall, and allow for direct comparison. I have found that this system is very helpful in improving the chances of achieving the patient's goals as consistently as possible.
Ultimately, careful communication of your goals (in my practice I prefer the use of goal pictures, direct examination/communication in front of a full-length mirror, in bra sizers, and computer imaging) as well as careful measurements (dimensional planning) will be critical.
Generally speaking, the best online advice I can give to ladies who are considering breast augmentation surgery ( regarding breast implant size/profile selection) is:
1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. ***Ask to see lots of examples of his/her work.
2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals. In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. For example, I have found that the use of words such as “natural” or "C or D cup” etc means different things to different people and therefore prove unhelpful. Also, as you know, cup size varies depending on him who makes the bra; therefore, discussing desired cup size may also be inaccurate. Again, the use of computer imaging has been very helpful during the communication process, in our practice.
3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery, after the use of temporary intraoperative sizers. I hope this (and the attached link/video, dedicated to breast augmentation surgery concerns) helps. Best wishes.