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Sizing up silicone: Dissection, insertion pearls leverage outcomes

Article-Sizing up silicone: Dissection, insertion pearls leverage outcomes

Key iconKey Points

  • Whether opting for silicone or saline implants, patients and surgeon's need to make educated choices, according to one expert
  • Silicone implants pose different challenges from saline and may require specialized surgical techniques

Dr. Cuzalina
TULSA, OKLA. — After a long dry spell, silicone gel-filled breast implants are making a solid comeback. Two years after their reemergence in the aesthetic marketplace, it's clear the fourth generation implants present an appealing augmentation option — but not without some caveats. Angelo Cuzalina, M.D., D.D.S., who sits on the board of trustees for the American Academy of Cosmetic Surgery, and practices at Tulsa Surgical Arts in Tulsa, Okla., tells Cosmetic Surgery Times that this renewed freedom of choice is a good thing, but requires education on the part of the patient — and the surgeon.

THE GREAT DEBATE It may be that, as long as silicone and saline implants are both available, there will be debate over which is best. While much is determined by patient (and surgeon) choice, Dr. Cuzalina says, "as far as the patient is concerned, the main reasons are that silicone implants feel more natural and they are less likely to show rippling." The flip side, he says? Patients must be made aware that gel implants may increase the risk of capsular contracture and will increase the difficulty of removal in the event of a leaking implant.

34-year-old patient before (left) and (right) four months after subglandular placement of silicone gel-filled implants. Patient had near grade 2 ptosis pre-op and preferred no major lift, a "natural look and feel" and minimal downtime. Gel-filled prosthesis offered a good alternative to a vertical mastopexy or submuscular saline implants.
From the surgeon's standpoint, silicone gel may be preferable, he says, when "the patient has thin tissues or previous augmentation with older gel implants, where placement of saline will very likely lead to a result that the patient may be disappointed with. The patient who has minimal ptosis — but does not want a lift — may also be a good candidate to place a submammary gel implant." Since the FDA reapproved the use of silicone gel implants in 2006, Dr. Cuzalina has seen a 54 percent increase in the number of patients in his practice requesting silicone. There are, of course, instances in which a patient should not receive silicone implants, for example, those for whom the silicone vs. saline debate remains unresolved. "Patients who have any significant reservations about the overall safety of silicone gel implants compared to saline implants, related to their health, should not get silicone gel implants," Dr. Cuzalina notes. "It is just not worth [the patient worrying] following the surgery that somehow they are a 'time bomb' waiting for some unknown illness."

That said, and once a patient has been determined to be a good candidate for silicone gel implants, the surgical technique can make or break the outcome.

TIPS AND TRICKS Clearly, because silicone implants are pre-filled — instead of filled after placement, as can be done with saline implants — the incisions must by necessity be larger. "Incisions for placement of saline implants typically range from 3 to 4 cm in length," Dr. Cuzalina explains. "Whereas, placement of pre-filled silicone gel implants usually requires an increased incision length to around 5 to 7 cm."

When surgeons encounter a problem inserting a gel implant, he explains, the choice of incision location — or even the length of the incision — is usually not to blame. Problems are more likely due to inadequate internal tissue release or improper tissue retraction. "A couple of nice 'tricks' or techniques to help with insertion," he notes, "include use of an 'iconoclast' dissector. This helps to spread and stretch the tissues from the incision to the pocket itself. Inadequate release of this internal tunnel heading to the pocket is a common reason for difficult insertion of the gel prosthesis. This is particularly important when placing a gel implant using the transaxillary approach, which inherently has a longer track from incision to implant pocket."

A thin, 32-year-old patient with minor ptosis before (left) and (right) six months following submuscular silicone gel implant placement. Photo credit: Angelo Cuzalina, M.D., D.D.S.
Dr. Cuzalina recommends use of "a long (6-inch), rigid right angle retractor during insertion rather than a shorter or curved Dever-type retractor...because it will help eliminate sagging internal tissue, making the insertion of the gel implant much easier."

COUNTERING COMPLICATIONS While capsular contracture can occur with both saline and silicone implants, Dr. Cuzalina says, "We're assuming that we may see more capsular contracture in the silicone gel implant group...but only time will tell."

However, one of the biggest complications relative to silicone may be the diagnosis and management of leaking or rupture of the implant. "Diagnosing a silicone gel implant rupture can be difficult," Dr. Cuzalina explains, "especially if it's a small leak. MRI may help but is definitely not foolproof. A leaking silicone gel implant still remains a challenging diagnosis. One really has to have a high level of suspicion for rupture of a gel implant when there's sudden capsular contracture or pain in a patient with an otherwise great result." Removal, he adds, is also much more complex than with saline implants, requiring extra surgical time. "Also, due to a severe inflammatory component that may also be present, placement of a JP drain is often beneficial to prevent unwanted fluid build up post-operatively."

ALL THINGS BEING EQUAL Dr. Cuzalina believes that, after obtaining thorough informed consent, "almost any patient who's had previously placed gel implants and was at least somewhat happy with the result, is a great candidate for...the new generation implants." Extremely thin patients can especially benefit from silicone, he adds, as can patients who have saline implants with minor rippling and want to go larger. At the end of the day, there's a reason so many patients opt for silicone — even after the notoriety of the 1990s: Many patients simply prefer the results they can achieve. The onus, as usual, is on the surgeon for outcomes that match those expectations.

For more information
Angelo Cuzalina, M.D., D.D.S.
[email protected]

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