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  • Both surgeons and patients are reluctant to fully embrace silicone implants because of their long-standing reputation as "the bad guy"

Yes. If you've sensed it, you're correct. There is a reluctance to put silicone implants in — both from the patients' vantage point as well as the surgeons' — mostly because we have had no less than 14 years of media coverage in which silicone was the bad guy; silicone caused deformities, and silicone created autoimmune diseases. Of course, all these claims were discounted early on, but that did not stop the attorneys from bankrupting Dow Corning and filing thousands of lawsuits that never should have come to pass. So, consider it a stigma. It is a huge one and it rides on both sides of the exam chair.

OPTIONS AND ADVANTAGES I think that if you were to weigh all of the pros and cons of silicone against those of saline and you looked at it strictly from one point of view (that being safety), saline would still win out by a small margin. In the years to come, this may change because FDA reapproval carries heavy stipulations of monitoring patients with silicone implants in the years following implantation. All things being equal, if you could assure a woman that she would have a perfect result with no hardening or rippling, silicone would be a much better implant with a more natural feel and appearance than saline.

BOTH SKILLS AND STIGMAS LINGER In terms of the potential that some of our silicone implant techniques might have gotten "rusty" as some have suggested, I don't agree that most physicians need to be retrained on silicone implants. We were always able to use silicone in post-mastectomy and for women who had problematic saline implants for six months or longer. Even younger surgeons who've come into practice in the 14-year marketing hiatus of silicone implants have had access to them. Yes, they are more difficult to insert, but I don't believe there is a re-education issue. Reasonably, we are required to take an online course to understand the nature of the reintroduced implant — as well as what the FDA is going to demand of us all. But neither has the background of litigation declined in the interim years — an atmosphere based on the inaccurate claims of many women. I think a lot of us still feel that sting and, therefore, there may be some personal reservations even though there is no clinical data to back them up.

PERSONAL, NOT ETHICAL And contrary to the opinion expressed by some of my colleagues, to me, the question of changing good saline implants to silicone isn't an ethical issue. It is a personal issue. Not personal for the surgeon — but personal for the patient. In the last few months, I've exchanged implants for a number of women who've had what I consider quite acceptable saline results but wanted to move to silicone because they have a softer, more natural feel. My opinion on it was irrelevant. It was strictly their choice.

Still, looking at this in the "big picture" setting, there has not been a massive charge of women seeking silicone implants. I was just interviewed for an article for our local paper, in which part was extrapolated from an article in the Philadelphia Inquirer, about the relative lack of interest in silicone since its reintroduction last November. Again, I feel that this is driven by the ever-present stigma of silicone over the last 14 years, so most women aren't dashing out to get silicone.

We now offer both silicone and saline implants to all patients, but, in fact, just yesterday I had a woman come in who, without a single pause or hesitation, stated that she would only consider saline. I didn't go into the whys, the wheres, or the whats. That was her feeling and that was her choice.

So while it's our responsibility to offer both, and to give the pros and cons of each, so far there remains a strong anti-silicone sentiment out there. And that means that, even though the FDA considers them to be safe and effective, from my vantage point, there isn't going to be a rush back to silicone anytime soon.

Dr. Popp is a fully certified Cosmetic & Reconstructive Surgeon in private practice in Omaha, Neb., and serves on the Editorial Advisory Board of Cosmetic Surgery Times . Since 1981, Dr. Popp has been an instructor of surgical anatomy at Stanford University.

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