Plastic and cosmetic surgeons have a growing list of options to choose from when recommending implant types to breast augmentation patients. Implant bells and whistles aside, Michael S. Kluska, D.O., immediate past president of the American Academy of Cosmetic Surgery and medical director of The Greenbrier Center for Cosmetic Surgery and MedSpa in White Sulphur Springs, W.V., says he thinks smooth round remains the primary go-to implant among U.S. surgeons.
In his hands, it’s the smooth round silicone gel implant with a moderate to high cohesivity.
“The smooth, round silicone highly cohesive gel implant provides a consistent result,” Dr. Kluska says. “They sit in the pocket more naturally. They tend to move more freely, kind of like normal breast tissue would. I think there is less potential risk for complications with smooth round implants than with textured implants.”
He’s less inclined to use contoured implants, which are textured in the U.S., as well as textured round implants because of studies suggesting texturing can lead in rare cases to anaplastic large cell lymphoma, or ALCL.
“It’s a rare type of low-grade breast cancer that is usually treated with removal of the implant and the capsule or scar tissue around the implant,” Dr. Kluska says. “We’re seeing this association with ALCL across multiple implant lines. It’s not just one company or one style but rather the texturing of the implant that seems to be creating this ALCL issue. But that isn’t proven yet.”
Researchers reported in a study published online October 2018 in Aesthetic Plastic Surgery on in vitro findings confirming that implant surfaces with rougher textures provide more surface area to harbor greater biofilm loads compared to smoother surfaced implants.1
Textured implants, according to Dr. Kluska, have a few other strikes.
“Textured implants tend to stick where you put them. So, if you don’t place them perfectly or the patient has an incident where the implant moves a little, it may end up healing there and could be stuck in a position that creates asymmetry or problems,” he says.
Saline Versus Silicone?
Smooth round saline implants fared well in the years that the FDA limited use of silicone implants, according to Dr. Kluska.
“The textured saline implants — they didn’t fare too well. They created a lot of rippling and a lot of problems with the need to have revisions because of malpositioning, etc.,” he says.
He notes that smooth round saline implants tend to ripple a little more and have a slightly higher rupture rate than silicone implants.
“The saline implant is a three-part system, whereas the silicone implant is a two-part system. The more parts, the more risk for failure,” Dr. Kluska says. “Usually, failures of saline implants occur at the port where we fill the implant.”
There remain health considerations with silicone implants, however. Researchers studying data for nearly 100,000 breast implant patients, 56% of which were silicone implants for primary augmentation, found that compared to saline implants, silicone implants were associated with higher rates of Sjogren syndrome, scleroderma, rheumatoid arthritis, stillbirth and melanoma. Authors of the study published September 2018 in Annals of Surgery found one case of ALCL, and that the short term risk for rupture is higher with saline implants, while risk of capsular contracture, the most common reason for reoperation in the data set, is higher for silicone.2
A newer implant type is the hybrid structured implant, which is an FDA-cleared saline filled implant by Ideal Implant. It’s saline filled with an outer silicone shell and a baffle structure inside that controls the flow of saline. The design combines the natural feel of silicone gel and safety of saline, according to the company.
Dr. Kluska says that while he hasn’t worked with the hybrid structured implant yet, he can see where it could become popular.
Gel density is another factor in implant choice, as today’s silicone-gel implants come in different grades of cohesivity.
“The higher the cohesiveness, the more gummy-bear like the implant,” Dr. Kluska says. “The true gummy bear implant available today from the major companies has a cohesivity level of 3 and primarily is textured.”
Implant size seems to be trending smaller, according to Dr. Kluska.
“I would say women are coming in looking for more athletic, natural and slightly smaller look than they did in the late 1990s and early 2000s,” he says. “We know now that bigger implants can potentiate bigger problems. Sizing the implant to make the patient have better anatomical proportions is always in the patient’s best interest.”
When to Consider Fat
Dr. Kluska uses fat for some breast augmentation cases, but those are limited, he says.
Surgeons might need to do multiple fat injections to achieve a patient’s desired cup size and fat can be unpredictable, according to Dr. Kluska.
“The average fat graft per breast takes from 20% to 70% of the fat cells that were transferred. So, if you’re going to get a 50% increase of volume on the transfer you may need to do it a couple of times to get what the patient wants,” he says.
The ideal candidate for fat grafting is a younger, healthy, nonsmoking, non-obese patient. Older patients with blood supply issues from smoking, heart disease or other conditions are less likely to do well with fat to enlarge their breasts, according to Dr. Kluska.
Disclosure: Dr. Kluska reports no relevant disclosures.
1. James GA, Boegli L, Hancock J, Bowersock L, Parker A, Kinney BM. Bacterial Adhesion and Biofilm Formation on Textured Breast Implant Shell Materials. Aesthetic Plast Surg. 2018 Oct 1. doi: 10.1007/s00266-018-1234-7.
2. Coroneos CJ, Selber JC, Offodile AC 2nd, Butler CE, Clemens MW. US FDA Breast Implant Postapproval Studies: Long-term Outcomes in 99,993 Patients. Ann Surg.2018 Sep 14. doi: 10.1097/SLA.0000000000002990.