Breast augmentation using silicone gel–filled implants

A e s t h e t i c S u r g e r y J o u r n a l ~ S e p t e m b e r / O c t o b e r 2 0 0 7 551

Breast Augmentation Using Silicone Gel–FilledImplants

Jack Fisher, MDDr. Fisher is Associate Clinical Professor, Department of Plastic Surgery, Vanderbilt University, Nashville, TN.

The author provides pointers for using siliconegel–filled breast implants. Technical differencesbetween the use of silicone gel–filled and saline implantsinclude the need for a longer incision for insertion ofgel implants. The author discusses patient selection,noting the variety of patients for whom gel implantsmay provide significant benefit including those withimplant rippling, minimal breast tissue, minimal ptosis,and breast deformities such as tubular breast. Theneed for proper size selection considering breast basediameter is emphasized. The author provides his viewson smooth versus textured gel implants and the role ofhemostasis in avoiding capsular contracture. (AestheticSurg J 2007;27:551–557)

In 1992, access to silicone gel–filled implants becamerestricted, and only recently have most of theserestrictions been lifted. Consequently, many plastic

surgeons in practice today have had either limited or noexperience using this type of implant.

After more than a decade of practice, in 1992, I, likemany of my colleagues, had to learn how to use salinebreast implants. At the time, I was primarily using sili-cone gel–filled implants in most aesthetic and reconstruc-tive breast surgeries and was intimidated by the verythought of using saline implants.

Nevertheless, I made a major change in how I per-formed breast implant surgery, while continuing tobelieve that silicone gel implants offer many advantagesover saline devices. Today, many plastic surgeons areeither switching back to gel implants or starting to usethem for the first time. Here, I evaluate the differencesbetween these devices and describe how to optimize theuse of gel implants. Some major issues to consider are:(1) What are the pros and cons of silicone gel–filledimplants? (2) What are some of the future problems thatwe will be dealing with, considering that large numbersof patients, over the last 15 years, have primarily receivedsaline subpectoral implants? Can silicone gel–filledimplants be used to resolve some of these problems?

(3) How do differences between gel and saline implantsaffect surgical technique?

The most significant factor in ensuring a successfuloutcome, as in all procedures, is proper patient and pro-cedure selection.1 No improvement in the attributes of adevice will ever obviate the need for surgical skill andsound judgment. However, there is no question that bet-ter products providing greater choices to facilitate obtain-ing the very best results are available today. In terms ofimplant choice, a 2006 poll by the American Society forAesthetic Plastic Surgery revealed that most plastic sur-geons, once they begin using silicone gel–filled implants,would primarily use round, smooth, moderate-profiledevices.2

I believe that the new generation of gels is superior tothose used in the past. First (and this statement may beproven incorrect), I believe today’s gel implants will pro-duce a lower incidence of capsular contracture, whetherplaced submuscularly or subglandularly, compared withprevious generations of silicone gel devices. Second, Ibelieve silicone gel–filled implants demonstrate fewerproblems with visible and palpable rippling, but with thecaveat that this variable will always be influenced, inde-pendent of the device, by the amount of breast and over-lying soft tissues.

I also believe that as silicone gel devices of varyingdensity or cohesiveness are available, we will have greatercontrol over shape. A bag filled with saline solution willnaturally assume a round shape; silicone gels may alsohave this tendency but, in my opinion, to a lesser degree.

To optimize results using these devices, I will discusspreoperative assessment; control and precision, includ-ing surgical technique and implant selection; and final-ly, strategies to decrease reoperation rates. (It is inter-esting that the number one cause of reoperationreported at the 2002 Santa Fe Symposium poll wasimplant malposition.)3

Preoperative Assessment

Assessment in the typical patient without significantcongenital breast deformities, undergoing primary breast

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The patient should understand that silicone gels aloneare not necessarily a complete solution for rippling.However, most patients demonstrating significant ripplingwith saline can be improved with silicone gel replacement.The key is proper patient selection. If a patient undergoessubmuscular saline implant placement, and still has visibleand palpable rippling, then silicone gels should be usedwith the patient’s understanding that this maneuver mayresult in improvement but not complete amelioration ofthe problem. Smooth silicone gel-filled implants are usual-ly a better solution than textured, since textured implantscan still have rippling problems, especially in very thinpatients with minimal breast tissue (Figure 2). One caveatrelated to rippling and implant surface is data that suggesta lower incidence of capsular contracture with texturedimplants.5 In general, smooth-walled, moderate- to high-profile silicone gels, whether subglandular or submuscu-lar, are more likely to resolve or reduce rippling issues(Figure 3).

One population in whom I believe we will see moreand more patients needing revision is the group ofwomen who, 10 to 15 years ago, underwent breast aug-mentation with saline submuscular implants. After agingand child bearing, these patients are likely to present withptosis and high riding subpectoral implants. In this

augmentation, includes analyzing inframammary foldlocation and nipple-areolar complex location and size,breast volume assessment, and evaluating symmetry/asymmetry of these variables. Finally, looking for chestwall deformities, which are surprisingly common, is criti-cal. If these breast components appear to be symmetrical,the surgery is fairly straightforward. However, many cas-es are not this simple. Preoperative assessment, includingthorough physical examination and evaluation of preop-erative photos, is critical. Photographs frequently revealabnormalities missed at the time of physical examination(Figure 1).

Before performing breast augmentation, the surgeonand patient should thoroughly discuss pros and cons ofsilicone gel–filled versus saline implants, including issuesrelated to implant insertion and location. Compared withsaline devices, silicone gel–filled implants require longerincisions for placement. Also, some insertion methodsused with saline implants are not appropriate with gels.5

Rippling, a major problem with subglandular salineimplants, can be improved with submuscular saline place-ment, especially if the patient has limited overlying tis-sues. However, relocation may not solve the problem inpatients with saline implants. Under these circumstances,silicone gel–filled implants may be of particular benefit.

Figure 1. Preoperative view of a 34-year-old woman demonstrates asymmetry of infra-mammary folds, nipple areola location, and breast volume, which the patient wasunaware of until they were pointed out. Recognition is critical in preoperative assessment.


A e s t h e t i c S u r g e r y J o u r n a l ~ S e p t e m b e r / O c t o b e r 2 0 0 7 553Breast Augmentation Using Silicone Gel–FilledImplants


Figure 2. Postoperative view of a 42-year-old woman with minimal breast tissue withvisible and palpable rippling 1 year after subpectoral textured gel augmentation.Textured gels are more likely to produce rippling when compared with smooth gels,especially if low profile devices are used.

Figure 3. A, Preoperative view of a thin 44-year-old woman with minimal breast tissue. B, Postoperative view 1 year following submuscular augmen-tation with saline implants demonstrates visible rippling. C, Postoperative view 2 months after correction of rippling with submuscular high profilesmooth-walled gel-filled implants. D, Fourteen months after correction, the patient demonstrates no evidence of rippling.

A

C

B

D




group, over time, the breast tends to descend while theimplant is held superiorly by the muscle, creating a char-acteristic look (Figure 4). Replacement of the saline sub-pectoral implants with subglandular gels is an excellentsolution in many of these patients. Some, however, willneed a concomitant mastopexy at the time of implantreplacement, depending on the degree of ptosis.

Unfortunately, because cohesive silicone gel-filledimplants are not currently available in the United States,discussion of this option has limited relevance. However,I believe, on the basis of my limited experience, thatthese implants are useful in patients with virtually nobreast tissue in whom implant shape can significantlydetermine final breast shape (Figure 5). Hopefully, thesedevices will become available in the near future.

Selecting an Implant

It is crucial to use breast base diameter as a primarycriterion in implant selection; this is true with siliconegel-filled implants or saline. Using an implant larger thanbreast width can lead to palpable or visible ripples.

Projection is determined by use of a low-, medium-,or high-profile device. A woman with a relatively narrowchest wall who wants large implants is not an ideal can-didate for a low-profile device. Implants are selectedaccording to base diameter and desired breast volume. Amedium- or high-profile implant is a better choice whenincreasing volume without exceeding appropriate basedimensions.

Breast sizers are a quick, efficient way to determineappropriate size and contour. I have used them for 25years, as do most of my colleagues (based on current siz-er-usage statistics). I do believe there is a direct correla-tion between excessively large implants and complica-tions. However, I eschew mathematical formulas,preferring to use aesthetic judgment. But, there are thosewho use formulas with good results, proving there aremany ways to reach a common goal.

It is imperative to become familiar with the character-istics of the silicone gel–filled implants that you use, suchas base diameter relative to projection. Each manufactur-er has specific charts, demonstrating width and relatedprojection for each volume of their low-, moderate-, andhigh-profile implants. Learning to apply these variablesin specific cases ensures proper implant selection.7,8

Technical Pointers

The most significant technical requirement in usingsilicone gel–filled implants is, first and foremost, the needfor a larger incision, compared with saline, for implant

insertion. Depending on implant size, a 4- to 5-cm inci-sion is appropriate. Forcing a gel implant through anextremely small incision may damage the implant, even ifthere is no visible tear to the shell. Additionally, instru-ments used during surgery may also damage the implant,with no apparent evidence during the procedure.9 Inpatients with adequate periareolar size, I prefer an inferi-or periareolar incision but also may use inframammary.In using the inframammary incision in patients withhigh, tight folds, the incision and final scar location canbe a challenge; with the periareolar incision, this is usual-ly not a problem. However, incision location is totally amatter of surgeon’s preference.10,11 It is important toremember that in an areola with only a 4-cm diameter, acurved incision becomes 5 to 6 cm in length whenstraightened. With inframammary incisions it helps toplace the scar lateral to the medial edge of the areolarplane, making the scar less noticeable (Figure 6).Incisions extending medially along the inframammaryfold are far more noticeable.

Another pointer is to limit medial dissection in thesubglandular pocket during implant placement. It is veryeasy to over dissect medially in an attempt to createcleavage, leading to a medial double bubble deformity oreven symmastia. The medial breast attachment is just asimportant anatomically as the inframammary fold breastattachment (Figure 7). Violating these structures can leadto problems, especially double bubble deformity. Onetechnique is to remain subfascial along the medial dissec-tion to limit implant palpability and visibility, but eventhis method has its limits. Over dissecting medially in thesubmuscular plane may be just as much of a problem.

In terms of surgical technique, proper hemostasis iskey in reducing capsular contracture whether a gelimplant is placed subglandularly or submuscularly. I wasoriginally taught to create the pocket with blunt dissec-tion followed by secondary hemostasis. However, formany years, I have preferred direct visualization withcareful primary hemostasis. Many of my colleagues haveadvocated this concept for years: more blood, more cap-sules; less blood, less capsules.

Silicone gel–filled breast implants dramaticallyincrease our ability to place implants subglandularly inmost patients. I do, however, consider placing gels sub-muscularly in very thin patients with minimal to nobreast tissue because in this group every bit of overlyingtissue helps. Patients with pseudoptosis or minimal ptosislook better with subglandular gels. As the breastbecomes ptotic over time, the subglandular implantdescends with the overlying tissue, thus avoiding an




Figure 4. Postoperative views of a 37-year-old patient 14 years after undergoing subpectoral saline augmentation. The breast has descended with time,while the implant remains in the subpectoral pocket superiorly.

Figure 5. A, C, Preoperative views of 21-year-old patient with essentially no breast tissue and a relatively thin pectoralis muscle. The inframammaryfold is also poorly defined. Cohesive gel implants require longer incisions for placement, but the incision location can be difficult to determine whenthere is little or no inframammary fold. In this patient, the incision location falls properly in the new crease, although the patient developed a thick,hyperpigmented scar. B, D, Postoperative views 1 year after subpectoral placement of anatomic cohesive gel implants. In this type of patient, theimplant shape determines the final breast shape.

A

C

B

D

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unnatural superior fullness, which can be seen in patientswith subpectoral implants.

Generally, silicone gel–filled implants tend to feelmore natural, look better subglandularly compared withsaline, show less rippling, and are better suited forpatients with minimal ptosis or breast deformities, suchas tubular breast. It is my bias that silicone gel–filledimplant products are superior to saline in achieving along-lasting satisfactory result in most patients. Althoughthe implant is a useful tool, proper surgical judgmentremains the most critical factor in optimizing results withsilicone gel–filled implants. ■

The author has no financial interest in and receives nocompensation from manufacturers of products mentionedin this article.

References1. Fisher J, Maxwell GP. Selection of technique for augmentation

mammaplasty. In: Noone B, editor. Plastic and reconstructive surgeryof the breast. Philadelphia: Mosby; 1991; p. 125–132.

2. 2006 American Society for Aesthetic Plastic Surgery Survey.Orlando, Florida. 2006

3. 2002 Breast and Body Contouring Symposium Survey. Santa Fe, NewMexico. 2002.

4. Dowden RV. Transumbilical breast augmentation: technically demand-ing, but safe and effective. Aesthetic Surg J 2006;26:337–340.

Figure 6. A, Preoperative view of a 23-year-old woman with inframammary incision location marking on the left. A silicone gel-filled implant will notfit through a periareolar incision in this patient. The incision is lateral and does not extend beyond the medial limit of the areola. Since a silicone gelimplant requires a 4 to 5 cm incision, the scar is better hidden in the inframammary fold in a more lateral position. B, Postoperative view 2 years aftersubglandular placement of silicone gel-filled implants. Proper placement of the inframammary scar is important in minimizing its visibility. In thispatient, the fold was slightly lowered.

A B

Figure 7. A, Preoperative view of a 27-year-old woman with a wide separation of the medial segments of the inframammary folds. Over dissectingmedially with subglandular gel-filled implants can create a problem with visible implant edges and rippling. The patient also has mild asymmetry of theinframammary fold and breast volume. B, Postoperative view 2 years after subglandular smooth walled moderate profile gel implant placement. Noattempt was made to extend the pockets medially beyond the natural folds. Also, creating a partial subfascial dissection medially can reduce problemswith subglandular placement by providing additional soft tissue.

A B




5. Barnsley GP. Sigurdson LJ, Barnsley SE. Textured surface breastimplant in the prevention of capsular contracture among breast aug-mentation patients; a meta-analysis of randomized controlled trials.Plast Reconstr Surg 2006;7:2182–2190.

6. Jones G. Breast augmentation. In: Nahai F, editor. The art of aestheticsurgery. St. Louis: Quality Medical Publishers; 2005: p. 1859–1906.

7. Maxwell GP, Baker MB. Augmentation mammaplasty: general consid-erations. In: Spear 5, ed Surgery of the breast; principles and art.Philadelphia: Lippincott Williams and Wilkins; 2006: p. 1237–1260.

8. Brandon HJ, Taylor ML, Powell TE, Walker PS. Microscopy analysis ofbreast implant rupture caused by surgical instrument damage.Aesthetic Surg J 2007;27:239–256.

9. Momeni A, Padron NT, Fohn M, Bannasch H, Borges J, Ryusm, StarkGB. Safety, complications, and satisfaction of patients undergoingsubmuscular breast augmentation via the inframammary and endo-scopic transaxillary approach. Aesthetic Plast Surg 2005;29:558–564.

10. Giordano PA, Rouif M, Laurent B, Mateu J. Endoscopic transaxillarybreast augmentation: clinical evaluation of a series of 306 patientsover a 9-year period. Aesthetic Surg J 2007;27:47–54.

Reprint requests: Jack Fisher, MD, 310 23rd Avenue N., Suite 101,Nashville, TN 37203. E-mail: [email protected].

Copyright © 2007 by The American Society for Aesthetic Plastic Surgery,Inc.

1090-820X/$32.00

doi:10.1016.j.asj.2007.08.001


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Breast augmentation using silicone gel–filled implants

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