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Michael Law MD Aesthetic Plastic Surgery

Cohesive silicone gel vs. saline breast implants: what’s right for you?

Located in Raleigh, North Carolina serving patients in Raleigh, Cary and Durham NC.

Let me start by saying that this is not a make-or-break decision in terms of your ultimate satisfaction with the results of your breast augmentation surgery. Saline and silicone gel breast implants are both safe and sound medical devices, and in the right hands both kinds of implants can produce breast augmentations that are beautiful, youthful-looking and natural-appearing. In all my years of practice, I have never had a patient in whom I placed saline breast implants return and ask to have them replaced with silicone gel implants, nor have I had a patient in whom I placed silicone gel breast implants return and ask to have them replaced with saline implants. I would be more than happy to perform either procedure for my patient that requested it, but thus far no patient in my practice has wanted to have surgery solely for this purpose of changing to the other kind of implant.

breast lift before/after

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That level of patient satisfaction is primarily due to two factors: the fact that both kinds of implants feel, for the most part, quite natural (as long as the volume is reasonable and the placement is correct); and the fact that we are very thorough in this practice with patient education. Patients who know exactly what to expect from the implant style that they choose, and who aren’t faced with ‘surprises’ post-operatively, tend to be very happy patients.

That being said, there are significant qualitative differences and performance differences between silicone gel and saline breast implants that are important to consider as you make your decision. Your anatomic starting point – the amount of natural breast issue and subcutaneous fat that you have to conceal a pair of breast implants – will figure prominently among the factors that you weigh, as will differences between saline and silicone gel implants in terms of what happens if and when an implant fails, and how implant failure is detected.

Silicone gel implants: the comeback

In November 2006, cohesive silicone gel breast implants became available in the United States for general cosmetic use, when the FDA lifted a 15-year moratorium on the cosmetic use of silicone gel implants. From 1992 through 2006, U.S. plastic surgeons could use silicone gel implants only for reconstructive purposes, most commonly for post-mastectomy breast reconstruction. During that time, the vast majority of cosmetic breast augmentations performed in the U.S. were saline implant augmentations. Since November 17, 2006 cohesive silicone gel breast implants have been FDA-approved for any woman age 22 or older who seeks a cosmetic breast augmentation.

So why did the FDA change its position on silicone gel breast implants? Primarily because the new cohesive silicone gel implants are a very different and vastly improved product. The manufacturers of breast implants in the United States were motivated by the FDA moratorium to address two significant problems that plagued liquid silicone gel breast implants: (1) the flimsy outer shell which tended to fail (rupture) early, and (2) a filler material (liquid silicone gel) that oozed out of the implants into the surrounding space when the outer shell failed. In most cases the leaking, liquid silicone gel was contained by the fibrous capsule that the body normally forms around any implanted foreign object. However, I and others believe that this liquid gel material is a potent stimulus for severe capsular contracture when it leaks out of a ruptured implant.

I regularly perform corrective surgery on patients with ruptured liquid silicone gel breast implants from the 70’s, 80’s and early 90’s. Most of these patients have immobile, unnaturally firm (and even hard) breasts, and at surgery we find extremely thickened, calcified capsules that must be completely removed along with the ruptured implants and liquid gel material.

The silicone gel breast implants that we use today are filled with cohesive gel material, which is in a solid rather than liquid state. It’s still a silicone gel product, and it still feels soft and breast-like, but it does not ooze out of the implant if the outer shell fails. If you cut a cohesive silicone gel implant in half, you end up with two halves of a solid implant, rather than a sticky, gooey mess. The outer shell material and design has also been improved, making the implants more durable and failure rates lower. The FDA took all of this into account, and gave cohesive gel implants a ‘green light’ for cosmetic breast augmentation in 2006.

Because the gel is in a solid state, cohesive gel implants feel somewhat firmer than liquid gel implants – but only a little firmer. I think that this is actually a positive change, as in my experience liquid gel implants simulate a soft, more mature breast (which is more fatty and less fibrous, typical of the natural breast at age 40 and over), while cohesive implants simulate a firmer, more youthful breast (which is more fibrous and less fatty, typical of natural breasts at age 20-30). Many of my patients who are moms in their forties relate that the cohesive silicone gel breast implants make their breasts feel more like they did before they were pregnant, which is an enhancement that they enjoy a great deal.

Making your decision

I have outlined below the main factors to consider when making your decision between saline and silicone gel breast implants. Different issues will have different levels of importance for each woman considering breast augmentation, so understand that the order in which the issues are presented is not significant.

Decision Point 1: How the implants feel

There is a very significant qualitative difference between silicone gel and saline breast implants that relates to implant palpability, i.e. whether or not you (or your partner) can feel them through the skin and breast tissue. Saline is non-viscous, and for that reason it tends to not support or ‘distend’ the contours of the implant shell very well at the outer edges of the implant. The gel material is in a solid state, so it supports the outer edges of the implant shell as well as it does the center of the implant. The difference is obvious when you hold a saline implant in one hand and a cohesive gel implant in the other, as we have patients (and spouses / significant others) do in the office during a consultation appointment for breast augmentation. The outer edges of the saline implant tend to collapse, creating obvious folds and ‘ripples’, while this happens only to a very limited degree with the gel implant.

When inserted behind the breast to enhance breast fullness, this means that a saline implant is often fairly easily to detect with your fingertips in the most lateral aspect of the breast where there is the least amount of breast tissue present to conceal it, and also in the inframammary fold area at the bottom of the breast where by virtue of gravity the implant is pressing down against the skin. Both styles of implants are soft and supple, and feel ‘breast-like’ when you feel them from the front – where they are better concealed by natural breast tissue and the pectoralis major muscle. But there can be a very noticeable difference in palpability between saline and silicone gel breast implants at the periphery of the augmented breast.

Decision Point 2: How well will my breasts conceal the implants?

The qualitative difference in breast implant ‘edge palpability’ described above varies in significance based on how much natural tissue (skin, subcutaneous fat and breast tissue) there is to conceal the implants. The patient who is 5’6″, weighs 125 lbs and has small A-cup breasts has a lot less natural tissue to conceal a pair of breast implants compared to the patient who is 5’6″, weighs 155 lbs and has full B-cup breasts.

For the first patient, who is slender, has A-cup breasts and may be interested in a C-cup breast profile after breast augmentation surgery, a saline implant will without question be easily palpable on the sides of her breasts and just above the inframammary fold. For this kind of patient I strongly recommend that she seriously consider cohesive silicone gel breast implants if she has not already, as her augmented breasts will feel much more natural to her (and to anyone else) with gel implants.

For the second patient, who is more full-figured, has full B-cup breasts and is probably interested in a ‘full C’ breast profile postoperatively, there is much less of a difference in the result she will get from the two types of breast implants. In fact, I have many ‘fuller figured’ saline implant breast augmentation patients in whom the edges of the saline implants cannot be detected by palpation, and who thus have saline implant-augmented breasts that feel completely natural.

If you are slender or small-breasted (and especially if you are both), and you feel that you have little to no tolerance for the implant being detectable by you or your partner, then it is important to understand that only cohesive silicone gel implants have the possibility of providing you with this result. It is also important to understand, however, that while silicone gel implants are much less likely to be easily palpable than saline implants, this does not mean that there is no chance of a gel implant being palpable in a very slender, small-breasted patient. It is just much less likely with silicone gel implants.

There is nothing wrong with choosing saline breast implants if this description fits you, as I have hundreds of slender and originally small-breasted patients who are perfectly happy with their saline implant-augmented breasts. They were counseled extensively prior to surgery that the edge of the implant will probably be detectable laterally if they feel for it with their fingertips, but that for the most part the augmented breast will feel soft and natural. There are therefore no surprises after surgery, and patient satisfaction is very high. I think another reason I have such a high rate of patient satisfaction with saline implants in my practice is that I do not use excessively large implants. The larger a saline implant gets the more likely it is to feel, well, like a water balloon. Saline implants at volumes of 400cc and higher, in my opinion, tend to feel much less natural than cohesive silicone gel implants of the same volume. For patients that require a fairly large volume implant, for example the patient who is 5’10” and wants to go from a small A-cup breast volume to a full C-cup breast volume, I strongly recommend cohesive silicone gel implants over saline breast implants.

Remember that prior to November 2006 almost all breast augmentation patients in the U.S. got saline breast implants (unless they were part of a pilot study for cohesive gel implants), and none of my saline implant breast augmentation patients have yet returned to switch them out for cohesive silicone gel implants. I think that this helps to quantify the ‘palpability difference’ between saline and silicone gel breasts implants in slender, small-breasted patients: it certainly makes sense to choose cohesive silicone gel over saline breast implants if you have the choice pre-operatively, but if you already have saline implants that were placed before cohesive gel implants became available there may not be enough of a difference between the two implant styles to make another trip to the operating room (to replace your saline implants with silicone gel implants) worth the effort and expense.

Decision Point 3: What happens if a saline implant fails?

When the outer shell of a saline implant fails, the saline leaks out and is immediately absorbed by the body. This is referred to as saline implant ‘deflation’ and it results in a patient suddenly having the appearance of being augmented on one side only. Most women want this corrected very quickly, and doing so requires a return to the operating room to remove the deflated implant and replace it with a new one. It is actually rather important to get this done as quickly as possible, as the fibrous capsule the body forms around a breast implant will begin to shrink when it is not distended by an inflated implant. So the longer one waits to have the implant replaced, the more extensive the surgery that has to be done to replace the deflated implant. Immediate surgery for deflation is a simple swap of a new implant for the deflated one, but delayed surgery usually means that the shrunken capsule must be released and a new implant space created – which if not done perfectly and symmetrically will result in postoperative breast asymmetry.

Decision Point 4: What happen when a cohesive silicone gel implant fails?

Silicone gel is inert and is not absorbed by the body, and in cohesive silicone gel implants the material remains inside the implant shell rather than leaking into the space around the implant contained by the fibrous capsule. So when the shell of a cohesive silicone gel implant fails, there are no signs or symptoms that this has happened. The breast looks and feels the same, and the only way a patient would know that one of their cohesive silicone gel implants has failed would be to undergo a radiologic study such as an MRI scan, which currently is the most sensitive and specific study for detecting gel implant failure.

This is sometimes referred to silicone gel implant ‘rupture’, but I think that term really reflects what happens to liquid silicone gel implants when the outer shell fails – the liquid gel material leaks out of them into the space contained by the fibrous capsule around the implant. These implants are no longer available, and I think the term ‘rupture’ should be discarded along with them. Implant ‘failure’ is a better term, I believe, for cohesive silicone gel implants, as the solid-state gel material remains within the outer shell when there is a break in the integrity of the outer shell.

Because cohesive gel implant failure is silent, i.e. there are no detectable changes in the augmented breast when it occurs, the FDA has recommended that patients receiving the new silicone gel implants undergo breast implant MRI screening for implant rupture at regular intervals following breast augmentation surgery. Postoperative MRI screening is a recommendation, not an FDA requirement, and the interval at which any cohesive silicone gel breast augmentation patient undergoes such testing is purely the decision of each individual patient.

Other considerations

As silicone gel implants are pre-filled, they require a slightly longer incision than saline implants for insertion into the surgically-created implants pockets, and the incision length of course varies with the size of the implant that is used. Saline implants are filled after insertion, and can therefore be rolled into a long, narrow shape for insertion through a smaller incision.

In my experience, the difference in required incision length for the two types of implants is not that great, and therefore usually is not a very important consideration in making the decision between silicone gel and saline breast implants. A new ‘funnel’ device is available for insertion of silicone gel implants which allows insertion of even larger volume implants through a relatively small incision, and it has the added advantage of delivering an implant into the pocket without allowing it to contact the patient’s skin.

One example of a situation where incision length may come into play is in when the areolar diameter is small. A patient with small areolas usually is not a good candidate for silicone gel implant insertion through a peri-areolar incision, while essentially any patient may have a saline implant inserted through that approach. I prefer to use the trans-axillary (underarm area) incision for breast augmentation in most patients with small areolas, and in that location the difference in the incision length for gel and saline implants is negligible.

If you choose saline breast implants, you may at some point be faced with the rather inconvenient need for surgery on a fairly urgent basis (ideally within a week or two) to replaced a deflated implant. And if you are slender and small-breasted preoperatively, you will have a constant reminder, in the form of palpable implant folds and ripples, that your breasts are bigger because of a pair of saline breast implants. You have the advantage, on the other hand, of never having to wander whether or not one of your cohesive silicone gel implants has failed.

If you choose cohesive silicone gel breast implants, you will have the luxury of a breast augmentation that has the most natural feel possible, and your partner probably won’t be able to detect the presence of the implants. You may not even be able to feel them yourself. The price of that luxury is the fact that you will not know if one of your implants has failed unless you undergo an MRI scan to screen for it. Gel implant rupture was formerly of great concern with liquid silicone gel breast implants, but is a great deal less worrisome with cohesive gel implants, as the cohesive gel material does not leak out of a failed implant.

So neither implant is the right implant for everybody. It is really a matter of what kind of result is acceptable to you in terms of implant palpability, and what kind if issues you would prefer to deal with postoperatively. Be confident that, whichever way you go, you can have a breast augmentation that is beautiful, youthful-looking and natural-appearing. And one that is satisfying to you for the long term.

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