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 Dr. Cuzalina |
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. |
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. |
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]
