Patient selection

Saline implants continue to have an important place in aesthetic breast surgery. In fact, the most commonly used breast implants in the United States for aesthetic breast surgery are saline. In my opinion, however, there remain certain patients who are better candidates for gel breast implants over saline breast implants. Certainly, since gel implants have become more available, many of us consider gel breast implants more broadly than was possible before January 2008. Nonetheless, despite the ‘opening up’ of the possible uses for gel breast implants, there are certain groups of patients in whom I continue to use saline breast implants.

One of the most frequent indications for the use of breast implants in aesthetic breast surgery is primary breast augmentation. In this group, patient selection is important. The primary quality which differentiates my general recommendation for a patient to have saline or gel implants is the pre-operative amount of the patient’s breast tissue. Akin to the amount of breast tissue is the amount of subcutaneous fat, particularly in the chest area. Usually these two qualities are closely related such that a patient with very small amounts of breast tissue is a fairly thin patient as well. This patient, who would properly be termed an A cup and a very thin patient with low body fat (less than 10%) is probably a better candidate for gel implants for primary breast augmentation. In these patients, the borders of any implant are felt, particularly inferiorly and laterally. In these locations, the less resilient or ‘thin’ feel of a saline implant may be more apparent as opposed to the thicker, more natural feel of the gel implant when in situ. Thus, the thin patient with scant breast tissue is a better candidate for the gel implant than the saline implant for primary breast augmentation.

All other patients, i.e. those with A–B cup breasts or larger and whose body fat would not place the patient in the ‘thin’ category, are probably better candidates for saline implants. First of all, the implant becomes less palpable peripherally as the patient gains body fat and breast tissue. The palpable nature of the breast implant remains the gel implant’s best advantage over the saline. As this becomes less of an advantage, the advantages of the saline implant take prominence. Significant advantages of the saline implant include less contamination upon insertion of the uninflated implant, a smaller incision with easier insertion of the implant, the adjustability of the saline breast implant, the fact that if they leak they only leak saline, and that the patient knows when the implant leaks. All of these are significant advantages of saline over gel implants.

While a whole host of causes have been suggested for capsular contracture, two of the primary causes for capsular contracture that are on everyone’s list are microorganism contamination of the pocket and silicone gel stimulation of the capsule itself. The fact that the saline implant is inserted uninflated markedly reduces the opportunity for contamination of the implant itself or the internal space for the breast implant. This is in marked contrast to the force that is necessary to insert a gel implant and is a striking advantage of the saline breast implant. Certainly, skin protection can be used, which does help with insertion of the gel implant, but clearly there is less opportunity for contamination with the saline implant insertion techniques as opposed to the gel implant insertion techniques. Alternately, when considering silicone gel stimulation of the capsule and its relation to capsular contracture, it is obvious that the saline implant contains no silicone gel and, thus, that causative factor is not present when saline implants are used. These advantages of the saline implant remain significant when advising patients upon their choice of saline or gel implants for primary breast augmentation.

At the time of the initial conversion from gel to saline in the United States in 1992, textured implants were in common use and were felt to be a significant improvement over smooth implants in terms of incidence of capsular contracture and naturalness of final result. The capsular contracture decrease was felt to be due to the texturing which ‘broke up’ the otherwise spherical smooth capsule around a smooth implant. The naturalness with a textured implant was felt to be due to the adherence of the implant to the capsule which stabilized its position on the chest wall giving a more natural relationship to the overlying breast as opposed to the smooth implant which could, and would, relatively slide around on the chest wall. This thinking accompanied the switch from gel to saline implants and thus most surgeons continued using textured implants. Over time it was noticed that capsular contracture, both incidence and intensity, was less with saline versus gel implants and it became increasingly clear that this was due to less contamination when inserting the saline implant and no occurrence of gel bleed as the implants did not contain gel.

As data was accumulated from both textured and smooth saline use, it became increasingly apparent that textured saline implants leaked more often and more quickly after implantation than smooth saline implants. Since capsular contracture was less of a problem with saline implants, it became obvious that the smooth saline implant was decidedly better than the textured saline implant and that is what we use today. Ultimately, though, it is the patient’s choice. Patients are encouraged to educate themselves through any legitimate means possible. This would include information and literature from the implant companies themselves, which can be found in hard copy or on the internet. Any strong desire to use one or the other type of breast implant is honored. On the other hand, it is important for the surgeon to discuss the pros and cons of each implant type as listed above. It is not appropriate, in my opinion, to push a patient into the use of either implant against their wishes. Indeed, either the gel or saline implant is quite successful in essentially any clinical setting for breast augmentation, even in the thin patient using the saline implant. If the patient expresses a strong antipathy to the use of gel implants it is probably not a good idea to force this issue even if one feels the gel im-plant would be better. Patients with strong antipathy one way or the other will continue to worry post-operatively.

In secondary aesthetic breast surgery, it is generally a good idea to use the same type of implant on the second operation as was used on the first one. This is because the patient has become used to the feel of the saline or gel implant over time. Thus, keeping the same type implant is almost always better accepted by the patient. A caveat to that is that almost every patient who has had previous breast implants is characterized by the compression of the overlying breast tissue and a thinning of the overlying coverage of the breast implant. This should be thoroughly discussed with the patient, as the gel implant may be the better choice, depending on the degree of thinning of the overlying coverage.

There is generally no need for the use of shaped saline implants in aesthetic breast surgery. With overlying breast tissue the round saline implant achieves, on the upright chest wall, a more contoured confirmation and, thus, a contoured or shaped implant is not needed. This is also true for gel implants, where the round implant achieves a more contoured position on the upright chest. The literature is filled with declamations of the round implant due to superior pole fullness, allegedly due to the round breast implant. This is not the case, however, as almost all this superior pole fullness is due to inadequate inferior dissection or the formation of capsular contracture, which shifts the implant superiorly and leads to superior pole fullness no matter what type implant is used. In addition, the round implant has no polarity and, thus, its position in the pocket is unimportant as it rotates naturally in the pocket postoperatively. This, of course, is not true for the contoured or shaped implants.

For reconstruction, the saline implant use is limited to that of tissue expanders. Obviously, tissue expanders must be saline so they can be adjusted appropriately post-operatively. A tissue expander is a device used to achieve a specific purpose, that of expansion of the overlying skin and coverage in particular areas of the breast, usually inferior. This device is not appropriate for the reconstruction of the final breast. Exchange of the tissue expander is almost always performed using a subsequent gel implant. Tissue coverage over implants after mastectomy is predictably thin, even when a muscle flap has been used. While the flap thickens the coverage over the anterior surface of the implant, at the periphery coverage is always thin. Thus, the gel implant is the best choice for the final implant in breast reconstruction.

Indications

Saline breast implants are indicated for primary augmentation in the patient who is not excessively thin and has at least an A–B cup of breast tissue pre-operatively. This, of course, is a judgement call and there are certainly patients who fall in a gray zone. On the other hand, results with either the saline or gel implant are so good that the use of a saline or gel implants in these gray zone patients is generally successful. Secondary aesthetic breast surgery usually follows the rule that whatever the patient had pre-operatively is usually used for the second procedure. Exceptions to this are patients who have a desire to change from one filler to the other. Often these patients are significantly influenced by previous leak of the breast implant. This can be the case with a saline implant that has leaked, causing the patient to want to use gel or the patient who has had a gel leak and now wants to use saline. In these cases, a patient’s desires are almost always followed.

On secondary aesthetic breast surgery if the patient’s tissues have thinned to a significant degree due to the longstanding breast implant, a gel implant is probably the best choice. There are a few indications for the use of the saline implant as the final implant in reconstructive breast surgery. There may be the very rare patient who has a very strong antipathy to the use of gel breast implants, but those patients are uncommon.