The Safe Implant
Years ago when patients said, “I want the safe breast implant,” I knew what they meant. Saline Breast Implants. Saline implants weren’t perfect. They rippled, they were heavy, and they felt like plastic bags filled with water (because they were). But they were filled with saline straight from an I.V. bag, a substance meant to be inside the body. Besides, old silicone gels could get hard. Rock hard. Compared with rocks, bags of water looked and felt really good. We used to use saline implants almost exclusively–not that we had a choice, since the old silicone gels had been banned. Even in 2006 when the FDA exonerated the gels of a long list of crimes and misdemeanors, patients still wanted the “safe implants.”
2006: Silicone Gel Implants Return
But a few maverick women did their research. They knew that the new silicone gels weren’t their mothers’ implants. Both the silicone gel and the implants shells had gotten better. And better. And better. Those brave few took the plunge, got silicone gel implants, and loved them. The new gels felt better, and they looked better. Word spread.
Now we hardly use saline implants. One of the main breast implant companies, Sientra, doesn’t even make saline implants. These days, when a woman asks for the “safe implants,” I ask her to clarify, “Which ones do you mean?” Of course, I’m prepared for her answer: “The ones filled with saline. If they leak, my body will just absorb it.” Yes, that’s true. But there’s more to an implant than safe saline.
The Deflated Saline Implant
Every year, roughly one in a hundred women with saline implants experience a deflation. In ten years, that’s one in ten. While intellectually it’s comforting for a patient to know her saline came straight from an IV bag, the breast with a deflated saline implant can look like a fallen soufflé. When a deflation happens on a beach vacation or a week before a wedding, the emotional tenor in a patient’s voice as she speaks to me can be frantic, like a Paganini violin.
Even if she knows the saline is harmless, she may call in the middle of the night or on a weekend because to her it’s an emergency. An emotional emergency. But there’s also a physical, biological urgency to replacing the flat tire. A deflated implant is smaller than a filled one, so the scar surrounding it (called a capsule) can shrink. The longer the shrunken implant sits inside the capsule, the greater the chance the capsule itself will shrink-until a replacement implant won’t fit. Not all capsules shrink. Some remain wide large and spacious, like a fully inflated balloon. But we don’t know the state of the capsule until surgery.
Treatment of a Shrunken Capsule
Ideally the patient schedules her surgery within a week or two of a deflation, since a delay makes shrinkage of the capsule more likely. If the capsule is kind and stays open, the replacement surgery is generally quick and uncomplicated. The surgeon enters through the old scar, opens the capsule, removes the old, shriveled implant and replaces it with a new one. Then the incision is closed, and the surgery is done. Afterwards the patient typically experiences little pain, and the recovery is easy. However, if the capsule has shrunk, a new implant fits like an adult foot in a baby shoe. In other words, it doesn’t. So the surgeon must create a space by cutting the scar (called a capsulotomy) or removing it (called a capsulectomy). Risks of capsule work include bleeding, nerve injury, possible breast distortion, and recurrent capsular contracture, and the patient’s recovery may be more painful and longer.
Saline Patients Switching to Silicone Gels
So, yes, saline is safely absorbed. But that’s only part of the story. In my own practice, the patient with a deflated saline implant nearly always switches to silicone gels. Those that choose saline again sometimes experience a second deflation, after which no one in my practice has opted for a replacement saline implant. Now that I’m using primarily highly-cohesive silicone gel implants for breast augmentation, my re-operation rate has dropped significantly. That makes me happy, because my patients have better things to do.