Canadian plastic surgeon Dr Mitchell Brown discusses the reintroduction of silicone gel breast implants in North America and the implications for plastic surgeons and their patients.

Canadian plastic surgeon Dr Mitchell Brown performs reconstructive and aesthetic breast augmentation surgery in Toronto, Ontario. In February at the 19th Congress of the International Society of Aesthetic Plastic Surgery in Melbourne, he presented his findings on the use of silicone cohesive gel breast implants in contemporary breast augmentation procedures after their controversial prohibition in the early 1990s.

‘Silicone gel breast implants were removed from the market in North America due to health risks in 1992, and from that time only saline implants were used,' Dr Brown says. ‘They were re-introduced after approval by safety groups in 1999 and were regularly and routinely used by 2006. Demand has driven choice, and silicone cohesive gel breast implants are the most popular option with patients today.'

However, as a result, some North American plastic surgeons, particularly those who trained or commenced practice during the period when only saline breast implants were available, have no experience with cohesive silicone gel implants. Dr Brown thinks silicone gel implants provide many benefits for the patient and, for this reason, it is necessary for plastic surgeons to transition within their practices in order to offer their patients that choice. His own experience and concern with transitioning led him to carry out a study on the subject.

His study follows 1,064 primary breast augmentation patients, who received 2,096 implants, 947 of which were saline and 1,149 silicone cohesive gel, from 1996 to 2007. By the last year of his study, 84 percent of patients received silicone gel implants; their use gradually increased with a concurrent decline in the use of saline implants.

‘The study shows several reasons for this,' Dr Brown explains. ‘Generally, both patients and plastic surgeons found better results were achieved with silicone gel breast implants. Therefore, both patients and surgeons became more accepting of the silicone cohesive gel product. This acceptance is part of the transition process.'

According to Dr Brown, the improved quality in the manufacture of silicone gel breast implants and the nature of their cohesive gel fillers, compared with the previous loose, liquid gel, meant that patients found their augmented breasts felt softer and looked more natural.

There are surgical considerations and decisions to be made by plastic surgeons because the way surgery is performed differs depending on the type of implant used. For example, the locations of insertion incisions are limited with silicone gel implants because they require a slightly longer incision than saline ones.

Silicone implants are more likely to have a textured surface, so post-operative management and massage instructions are different from those for saline implants. Biodimensional anatomical silicone implants also necessitate the surgeon to be more precise when creating the cavity for insertion.

‘The study showed that both the complication and re-operation rates were lower with the use of silicone gel implants,' Dr Brown says of the differences in clinical outcomes.

The reintroduction of silicone cohesive gel breast implants to the North American market also necessitates the retraining of practice staff, and the creation of new consent and patient information forms. This means an increased demand on staff and increased time allocated for consultation with the plastic surgeon.

In his own practice, Dr Brown's preference is for the silicone gel implant. ‘They're softer and more natural-looking in both feel and look,' he says. ‘The complication and re-operation rates also appear to be lower.'

However, Dr Brown is adamant that patients' preferences must be taken into consideration. He says if patients wish to minimize the length of their scars - via an incision around a small nipple, for example - a saline implant is a better choice. ‘There's a role for both saline and silicone cohesive gel implants in treating breast augmentation patients,' Dr Brown concludes. ‘No single implant or surgical approach is right for every patient. Having choices improves the overall quality of care, patient outcomes and patient satisfaction.'

ACSM #39