So we want to dive into where are implants today that are offered out right now, because things have changed so much over the last five years.
There’s a lot of area to cover here. So it’s hard to even know where to start. My consults have become so overwhelming even to me because when I started fresh outta residency, there was saline and silicone. Thankfully, my second year of plastic surgery residency, silicone came out, which is why I waited till second year of residency to get my implants. Because I wanted silicone. Now they just keep releasing new, improved versions of implants.
Just to keep getting better and better and better. So yeah, they don’t give up. They don’t just say, “This is what it is.” Even if there’s nothing wrong with it they just continue to keep making them better. No matter how safe and good implants get, they’re devices and they can always be improved upon.
This is the saline implant that’s an empty silicone shell. So for people who want natural and are afraid of silicone, this still has a silicone shell. It’s just not filled with silicone. It’s filled with IV saline, which basically will kind of get absorbed by the body if the implant deflates. I can understand where some people are coming from, though, because this is a solid silicone shell. It’s really not going anywhere or doing anything, and I think the big concern patients had for long time was, “Is there gonna be runny silicone all over my breasts? Is it gonna get into my lymph nodes? Is it gonna make me sick?”
So previously, especially the first generation of implants, they were like lava lamps. Super runny, gooey, sticky; it almost reminds me of honey. I’ve taken out a lot of those super old implants, it is gross and goopy. These days, the silicone has been improved tremendously.
So, we’re going to talk about the old ones first. These are, now I use Allergan implants so I’m talking Allergan brand names, but these concepts really go across the board for the different implant manufacturers. These are what are called Classic Gel implants, and if you’re not talking Allergan, they’re called Generation Four Gel. This was the gel that they studied when implants were taken off the market and brought back on. If you could feel these, they’re pretty soft.
I hold them flat in our hands. There’s a little dimple or divot at the top. This was intentional at the time because they wanted to keep the implant soft and when you put this on rounded rib cage, it does fill out. It bows, it pushes it out. The problem is, once peoples’ tissue would stretch and once this implant was in for years and years. They want it to do that. They get sad. This is still heavy, runny gel. So kind of, this is it at first, and then it goes over time and this is what happens to the upper part of your breast. It ends up being more flat, and a bubble.
So to give people more of that upper pole fullness, one of the things the implant companies did was overfill the implants. So that’s where this came in. So instead of this, we’ve got this, which is slightly more rounded and it did a great job of maintaining upper pole fullness- There’s more upper pole fullness, but it still over time has a tendency for that gel to want to settle to the bottom. So a big excitement came out when these Gummy Bear implants came out, not just because they’re shaped differently, but because look at this gel. It is so stiff. But now we have that same thicker gel in a round, smooth implant. If you look what happens when you tilt these straight up, this older gel, even though this is overfilled, still wants to rush to the bottom. The newer gel stays put and is much more like a solid than a liquid. If you were here to touch and feel them, you would realize that they are definitely more, not firmer but just definitely more cohesive on the gel which overall keeps everything nice and fuller longer than the other ones do. That was the whole point of them. The most responsive, I mean, the most cohesive one, we don’t use that much of.
So let me explain a little bit more the differences. So this is the older gel, the Classic Gel. About 91% of the silicone molecules are cross-linked to other silicone molecules, making them behave as a unit rather than free-moving silicone. This is 94% cohesive, this is 97% cohesive. So there are only little jumps and differences between these. Most patients will notice internally the difference between this implant and this implant. Unless you are extremely thin or really sensitive to the sensation of rippling, most patients are not going to need that strongly a cohesive implant.
Now back to the Gummy Bear implant. This is very different conceptually from these because this implant is meant to have tissue grow into it. It’s textured. So when you put this implant in, the downtime is almost double, especially under the muscle because you can’t have any fluid accumulate around this, you can’t have it shifting around or it won’t stick in the right position.
But so many people come in and they’re like, “Oh my gosh, I heard about the Gummy. It’s the best thing since sliced bread. I need it.” It’s good for some patients. The positive things about this are, because it grows into the tissue it can stick in place and keep its position over several years better. But if it’s placed too high in surgery, or if something happens during recovery where it sticks in the wrong position, it can kind of be a nightmare to fix. People want a natural look with this implant but it takes about 6 to 12 months to get a natural feel. We had that patient on Monday, she stated “I just wanted a natural slope and now I have this bulk of boob up here and nothing down here because they just didn’t settle or they were placed too high. And I told her most likely the surgeon just placed them too high and too far in on the chest, and that’s OK with these implants ’cause they tend to settle.
These are also linked with something called ALCL. That’s been in the news a lot. I don’t know how many patients are really aware of it, But it’s a form of lymphoma that they’ve found in around 400 women that have had textured implants at some time in their past. It’s still being studied. The FDA is not calling for removal of these implants or recalls or not putting them in, but for patients who don’t want that at the back of their mind. I think that in order to make a decision to something like this, you really should know everything that’s out there. We’ve had so many women that come in and have implants from within the last 5 or 10 years, “What size is it?” “I don’t know.” “Is it silicone or saline?” “I don’t know.” “Is it under or over the muscle?” “I don’t know.” So I like to make sure patients understand as much as possible about what they’re signing up for when we do surgery.
I tend to talk those patients more about using smooth, round implants ’cause they are a little more forgiving. So it’s kinda funny, since I started practice, it’s been about 10 years, the style of breast has changed. We are shifting volume from here to here, and everybody now wants perky, little B- or C-cups, whereas before it was this full DD look. And not that there aren’t individuals that still want that.
Oh yeah. Like Pamela Anderson and Baywatch. But more of our patients are coming to downsize their implants, do lifts, and get something smaller. So, whereas 10 years ago this guy was pretty popular, this nice 500 cc, extra high profile, super round implant-These are more popular now. A more natural profile than instead of sticking out and being very round, is much more natural shaped. Or just going for a tinier implant in general. And of course it depends on the person. People always ask me, “What size implants get you to a C-cup?” Well, it definitely depends on-What you have, how big your rib cage is, and how the implant sits on your chest.
So it’s definitely different from person to person. “Well, she started with an A-cup, she got a 325 high profile, so that should be for me.” Well, not necessarily. She could be 5’2″, you’re 5’9″. I think also, talking on that real quick, you talked about going from bigger to smaller and that kind of style. I’ve kind of developed over the years, basically a three-step sizing process. So, the first visit we take measurements. We talked about the breast footprint last week and how important it is for longevity and safety to try to stay within that. So based on breast measurements, we know a range of implants that are going to fit on the chest.
Then we have patients try on a sizing system, we have patients try on in a sports bra, increasingly large sizes. Not the actual implants, ’cause those don’t always show up like they would under the muscle. These are anatomically shaped little cutlets. According to sizes of volume of cc’s to the kind of idea of what they would be in an implant. It gives me a much better idea of whether someone’s looking for a small change or a big change. Some patients, I expect that they’re gonna like a 250 cc and they just keep going to 450. Other patients, we put the 250 in and they’re like, “Whoa, this is too much.” Or they even ask “Do you have a 100?”
Implants come as small as about 120. But, if you’re a large person and your chest is this wide and we put a little 120 in, it’s gonna look like a little BB, so again, it’s all proportional and all relative. So this is our sizing system. We have everybody use this genie bra to kind of hold the implants in place. And then these are the sizing systems that we use for mentor- to give us an idea of how much volume someone’s looking for. So that’s step two of our process. The third step of the process is to review photos with patients. Not so much so I can guarantee what they’re gonna look like, or what they’re going after, but I have them bring in a few pictures of breasts they like and a few pictures of breasts they dislike.
Definitely, because you can get so lost in looking before and afters, and you’re never gonna find yourself… You’ll get so lost in it to find something better than to be, like, on Instagram. Boob boards on Pinterest. People in bathing suits, people in low-plunge dress lines where they like the cleavage or they hate the side-boob in a bathing suit. It’s a visual. It is a visual, ’cause some people, I’ll ask at the first consult, “Do you have any preferences about upper pole fullness or side-boob or cleavage?” And some people hae very specific ideas. Other people look at me like a deer in the headlights. Like, “I have no idea what you’re talking about, I just want them bigger.” So that’s where pictures come in handy because they don’t need to know the lingo and know the words. Super DD, crazy, fake-looking. And to her, that was a natural C-cup. So that’s why I prefer pictures versus just discussing things. So, after we have all of that information, my final step is to look at the implant catalog and look at the measurements of the implants, compare those to the breast measurements, compare the volumes to the volumes we liked trying on, and usually we’ll come up with a range of sizes that feels appropriate to the patient.
Intraoperative sizing is very important. Many surgeons will not size intraoperatively and I’m not saying there’s necessarily anything wrong with that. But, when you’ve got asymmetry or you’re not sure of how the muscular anatomy is internally and what kind of implant can truly fit in someone’s chest, then it can be helpful to bring the actual silicone implant sizers to the operating room ’cause they’re identical to the permanent implants. That way I can try on different volumes, sit people up, compare side-to-side, and know that I like the volumes we’re putting in before we open the permanent implant.
We do surgery with arms at the sides because when your arms are out, it gives you a fake perception of where your nipple is. Especially during lifts. They look great until you put your arms down. So we do surgery with the arms down. And it’s subtle little things like that can actually kind of effect how your result turns out.
THE INSIDE OF AN IMPLANT
OK, guys, so the reason we’re gonna cut one open is because there is a little bit of a difference from the gel from the old ones to the new ones, but understand this, it would take a lot, a lot of something to rip your entire shell open of your implant.
Well, let’s talk about rupture. So, my husband is a 14-year-old at heart. He has driven over these implants with his truck, he has set firecrackers off under them, and they don’t rupture. It is much more chronic wear and tear. So these older implants that have this gel that’s looser and it can fold and bend, it’s like bending a credit card back and forth, and it just gets a weak spot. And then if you, God forbid, get in a car accident or get a mammogram, it’s just that last final straw in an already weak place.
So, it’s not like your implant, unless it is in the breast tissue behind the breast- Well, it’s still in a capsule behind the breast tissue. It’s still in a capsule. Your capsule forms pretty quickly after surgery which almost consider it like a eggshell, like a little eggshell that starts to develop around the implant. It would be very hard, unless that capsule is broken, for that to penetrate through an eggshell.
Usually if you just get an isolated tear in the implant, and not a tear in the capsule at the same time, which is the more common way that it happens, then you have a little gel shatter inside. Well, this, if you get a tear in the implant, most of the time your capsule, your own tissue is still intact, and it just keeps all the gel in there. Most people don’t even know that their implant’s ruptured.
Well, and the company also says, I mean, if there’s a defect, it was kind of something from the beginning. Could be. Sometimes. And that’s why they do carry a really good warranty on the implants. Most implant companies nowadays have a lifetime warranty on the replacement of a device.
Patients under 22 can get silicone implants, but in the U.S. you void your warranty because the FDA didn’t technically approve these devices for use on patients under 22. It’s not that they’re not safe for people under 22, but when they did the study they didn’t have enough patients under age 22 to be able to safely say these work. We have patients who come in and are like, “I’m gonna be 22 in six months.” We’re like, “Wait.” If you’re 19 or 20, and you want breast aug then that’s a long time to wait if you really want one.
So in those circumstances, some patients will choose a small, what I call Starter Saline, just to get a little volume in there but not push the envelope. That just bides you time and is a safe way to make room in the pocket so you can switch to a silicone later on. The other option is just to go ahead and get the implant and understand you’re not going to have warranty. And it doesn’t magically activate when you turn 22.
So in general, we can talk about two types of scarring with surgery. External scars, internal scar, which is more talking about capsule and capsular contracture. Unfortunately, any repeat surgery you do does carry a slightly increased risk of capsular contracture. Revision rates are higher than primary augmentation for sure.
A straightforward exchange, though, if you’re just, if you’re happy with the look and the feel, you just want silicone instead of saline and you’re not changing the size tremendously- It can take less than an hour in surgery. We open up the incision, we put the implant in. If we don’t do internal dissection, it’s almost, almost a risk-free surgery with a very easy recovery.
It is pretty straightforward, and your chances of external scarring usually aren’t higher. But, it does carry the slightest increase in risk of capsular contracture, especially if we go putting a bigger implant in and scoring the capsule to make room for it.
Or if you’re downsizing, and you might have to have a lift, there’s a couple, there’s so many different factors into what you’re trying to achieve from doing an exchange but if you’re doing a cap-con, having some capsular contracture and removing all that stuff, it just gets a lot more… Like the one patient we had, I mean, she had capsular contracture, hard boobs that were up here, and definitely had a reason and a validation to get them out, but when she did remove them out and all the stuff was done, she got a little tethering on the nipple incision.
That’s one of the reasons I don’t like peri-areolar incisions. Even though when they heal well, they’re a fine line at the edge of the areola, I’ve seen way too many patients lose pigment, or have darkening or tethering. When we have tissue and we cut through multiple layers of tissue; skin, fat, muscle, breast tissue. There’s four layers of tissue there. They almost can fuse together at the incision site and cause this permanent pucker that can be really tough to fix. Sometimes you can cut that scar out, but there’s only so much areola and breast tissue and especially if you’re upsizing, there’s no wiggle room to take anything out.
Either you have to make the incision on the areola and dissect under the skin over the breast tissue till you get to the bottom of the breast, which can cause skin discoloration and can cause some funky scarring along the center, or you cut right through the breast tissue, which I have seen a couple of surgeons do, which increases the risk of infection and capsular contracture. ‘Cause there’s bacteria that live in our breast ducts and our nipples and cutting through breast tissue is going to expose your implant to more of that.
Incisions are peri-areolar meaning around the nipple, or down underneath the fold. The ones underneath the fold, once everything settles, the goal is to have that implant fold over and cover and hide them back up underneath your breasts.
The incisions are about four centimeters, although, if they’re the new, more cohesive implants and they’re bigger than about a 300 or 350, I’ve been making them 4.5 cm. Since the gel is more solid than liquid now, it doesn’t squeeze as easily through an incision. You can get something called Gel Fracture.
There’s a little area where it looks a little more translucent. It’s almost as if the gel has cracked. If you put it through too small of an incision, or if you put too much force on the implant, it can crack your gel. It’s not necessarily a rupture risk, but it could be. The implant could be more likely to fold in that area.
So, that’s one of the reasons that for textured implants and for really large implants, we use a Keller funnel to put them in. The Keller funnel basically looks like a cake icing bag. And you just put the end of it in the incision and squeeze the implant on in. They’ve shown in their studies that it decreases the amount of force and pressure on the implant, so they’re much less likely to crack and it protects the implant from touching the skin and the breast tissue and areas with bacteria on the body. So, we’re a big fan of the funnel.
We’ve had a lot of patients who have come in and they only have had implants in maybe since 2014 or something, and they’re just like, “Well, I’ve been told I’m supposed to switch these out. So I’m here. Hi.” And we’re like, “Well, is anything wrong with them? Do you have any issues, complaints?” “Nope.” So, let’s go on to that lovely, good old… Debunk the 10 year myth.
There is no 10 year myth.I think that may have started because if you had a saline implant, and you truly wanted to try to catch it before it ruptured, based on the average rupture rate, it was suggested to people, or maybe they did a study on average people had them replaced every 10 years. These newer implants could be in there 30, 40, 50 years before something goes wrong. The FDA recommends for silicone implants getting an MRI every couple of years.I’ll be honest, I’ve never gotten an MRI. I’ve had ultrasounds. It sometimes shows up on ultrasounds. It sometimes shows up on mammograms. It just gives me peace of mind.But that’s the thing; every patient can make that choice.
It’s a recommendation by the FDA, not a requirement. It’s a cost most insurance companies are not going to cover. If you think you might have a rupture, and it’s because of a symptom, you may just want to have a surgery to correct that symptom anyway. But if they’re perfectly fine and you don’t have any issue with them…If it’s not broke, don’t fix it.
They did a study. The first round of patients that followed those recommendations, they found that there were a few false positives and a few false negatives. So, people where they had a scan, it said, “Your implant’s ruptured,” and then they went to surgery and it was fine. They ended up having surgery for no reason whatsoever. There were also a handful of patient who it said the implant was intact, and then they ended up having a surgery for another reason, and it was ruptured. So no test is perfect. I leave it up to patients and I kind of explain the pros and cons. The advantage of getting an MRI and checking is you may catch a rupture before it has a chance to potentially have a side effect.
Let’s talk about some of the side effects.
So, if a silicone implant ruptures, most of the time, like we said, your capsule keeps that silicone in place and it doesn’t affect your body at all. They have shown that if it’s ruptured for several years, in some patients, that can convince your body that there’s something inflammatory going on and it can be a trigger for capsular contracture or hardening of your capsule, and it can cause pain.
In some patients, this is even more rare. But in some patients, that gel can actually on a microscopic level bleed through the capsule, or if there’s a tear in the capsule, it can ooze through the capsule and contact the breast tissue. That’s, I think, why this is important. This gooey silicone implant versus this more cohesive implant, is going to clearly make a big difference inside your body if it ruptures.
Dr Dana’s Implants
So, I understand the roller coaster of implant surgery because I’ve been on it for eight years. I have simultaneously at times been in love with them, hate them, want them out, want them bigger, want them smaller. It is a normal thing to keep wanting to do something that’s slightly different. I got mine because I had really small boobs. I didn’t like it, and I felt like I looked like a little boy. I felt like when I bought dresses, the tops were baggy sometimes and I bought two-piece suits and they just didn’t fit me right, and so I got silicone implants.
So… two stories about that. One is the 3D imaging and this is why I don’t use it. I had a size picked out in my head. A nice 350 to give me a C-cup. Asked for a C-cup. Went into the consult, it was a surgeon I did, and do still trust greatly. We did the Vectra 3D system and the 400s looked amazing and my husband was there and it was amazing, and we went bigger. Although I’m fine with it now, my posture changed and I felt like a different person for years. I got stretch marks on my breasts, and they got saggier, and my dad called me matronly at one point and it just… I’ve been on that ride.
At this time, I was a plastic surgery resident who didn’t want other plastic surgeons to know that I had surgery. But I remember the week I got them done. I was in an operating room with an anesthesiologist who was badmouthing women who were getting implants and saying, “All these women getting implants, they just stick their chests out, and they just want everybody to notice.” And I’m sitting there in the room a week post-op thinking, “You are an asshole, lady. And you’re also clueless ’cause…”
But that’s the funny thing about implant surgery. For most people, when you get the implants, your muscle squishes it super tight against your chest. No one’s going to know right away. The projection does not look like you think it’s going to look. I thought I probably had a B-cup when I came out of surgery with pointy torpedo nipples. And then a year later, they had settled into F-cup breasts which was a little shocking.
Implant Revision Surgery: The Popcorn Technique.
So, revision surgery for implants is something we’ve done a lot more of, and it’s kind of cringe worthy and kind of rewarding ’cause it’s really complicated and unpredictable. Yet, you can make some real changes in women sometimes. So I have a ton of patients who had had surgery years and years and years ago, and when they lay down their implants just fall into their armpits, or they’re bottomed out, meaning the implant has settled way below the breast fold or below the nipple and the nipple looks like it’s on top of the implant, looking at the ceiling.
So there is something I learned from a Swedish surgeon that’s called the Popcorn Technique. It uses heat and cautery, when you have an existing capsule, to kind of strengthen that capsule.
In my residency they taught us all kinds of suturing techniques, and the problem with suturing techniques is if you think about the capsule being a pair of pantyhose, an overly stretched capsule is like a pair of pantyhose that’s lost elasticity. You can tighten those with stitching and hem them till the cows come home But they’re not going to get more snap to them, so with this heat cautery technique, there’s video of it posted online, you can actually watch the tissue kind of contract before your eyes.