Cosmetic Surgery Associates Blog
Everybody knows that silicone implants are great. They were reintroduced to the American market in 2006 and have been very popular. So why change things? The gel filler used in silicone implants allowed for round implants and let them deform with gravity to a soft somewhat breastlike shape. The slightly stiffer gummy bear implants allow the shape of the implants to hold a teardrop (or anatomical) shape.
Many of my patients still like the round smooth implants because the restore the upper fullness (think cleavage) and roundness that mature breast tend have lost with age or pregnancies. But for someone who wants a stealth augmentation, with less evidence of this unnatural (but often desired) behavior the round smooth implants leave something to be desired. Enter the “Gummy bear”; with its stiffer composition it could provide maximum fullness at the bottom of the breast with little or no evidence of its presence at the top of the breast slope. In 2012 the first shaped silicone implants cleared FDA approval and there are now three manufacturers (Allergan, Mentor, and Sientra) who provide these newer shapes. Sientra implants are the most like the round gel with the most upper fullness of the shaped devices. The Mentor memory gel implants are intermediate in the upper fullness, and the Allergan Style 410 is the flattest at its upper edge. All the manufacturers have a range of styles (and of course, sizes) within each type of implant.
Most of the gummy bear implants I put in are for reconstruction patients, where it is more common to want less exaggeration of the upper pole to minimize the “coconut” appearance of the reconstructed breast. And the added stiffness is relative. These are NOT hard immobile rocks in your breast; for people who desire a more natural augmentation, the shaped silicone implant can be wonderful.
Saline implantshave been around forever, but became widely used after 1990 when the FDA began questioning the use of silicone implants. They have an identical shell as silicone implants, but the difference lies in the filling. As the name suggests they are filled with sterile IV solution (saline). The water in the solution has less viscosity (like water is less thick than motor oil), so it is more likely to show rippling or dimpling of the shell in women who are very slender and have little breast tissue or body fat to hide it. The consistency of the implant is a little firmer and a little stiffer than that of silicone. These two properties make the implant more palpable (you can detect the edges of the implant more easily with careful palpation at the lower outer edge of the breast where there is no muscle coverage.) That’s why saline implants are always placed behind the muscle, and if you want your implant in front of the muscle you should choose silicone. So why would anyone ever choose saline over silicone ? The answer comes with maintanence considerations. Saline implants are basic place it and forget it implants. If anything ever goes wrong with them (such as deflation or leakage) the saline is simply and harmlessly absorbed by your body and goes out through your kidneys. At that point, the implant will become flat and you will obviously know what has happened. (no expensive tests). Replacement is almost always a simple inexpensive office procedure and is unlikely to involve any serious recovery time. Most implants have a life time warranty and the replacement implant is usually free. The cost to replace a deflated implant varies in our office by who put them in.. I give a VERY significant discount to my patients, some discount to those put in by my former partners, but even at full price it is way cheaper than when your implants were put in initially. At the time of replacement surgery you can choose to have both implants replaced, change sizes, or even correct some of the features you didn’t like about the previous or ruptured implant(s).
Silicone implants have also had a long history but were unavailable for cosmetic use from about 1990 until 2006.They are filled with a silicone elastomer and recently there have been some implants introduced with even thicker elastomers (gummy bear implants). For the most part you don’t need to dwell on the thickness (or G factor) of the elastomer, just know that for shaped implants the gel needs be more cohesive to prevent shape change and undue rippling. The typical round smooth implants are softer, less detectable, and are actually less likely to leak or deflate than their saline counterparts. So where’s the catch? The silicone elastomer will be trapped inside the body’s scar capsule if there’s any leakage outside its shell. And that’s a good thing. If we knew that it would stay there forever, there wouldn’t be any harm in that. BUT, the gel won’t stay inside the capsule if ANY damage happens to your bodies scar tissue. Simple bumping into furniture, exercise equipment, or falls to the ground can disrupt a fragile scar capsule. Even if the capsule remains intact, gel bleed can make subsequent capsule contracture problems. Suffice it to say that if the silicone gets out of its shell, the whole implant (and usually the accompanying scar capsule) needs to be removed. Generally this is done in a surgery center under general anesthesia which makes it a bigger deal than simple office replacement of a saline implant. Just to complicate matters more, it’s not obvious when leakage occurs. To find this silent leakage requires an MRI scan (mammogram and ultrasound are notoriously unreliable) which can be expensive. The current manufacturers recommend an MRI three years after implantation and every other year thereafter. You may argue with their guideline on an epidemiologic basis, but bottom line is that you will need some sort of regular surveillance program FOR LIFE.
The analogy I give my patients during our consultation is generally like that of choosing a car. If you want the reliability and convenience of standard auto makers with an oil change at Jiffy Lube without an appointment, you want SALINE implants. If you want to take corners at 60mph and don’t mind making an appointment with the dealer a month in advance to have your high performance auto serviced, then you’ll probably want SILICONE implants.
There are lots of nuances to this discussion, so if you have more questions leave a comment for me, or better yet come in to our office for a private , personal consultation with Dr Zickler to have your individual specific questions discussed.
Whenever anything is placed inside a healthy human, her body begins to build a protective covering around it. Since this covering encapsulates the implant, it is called a breast implant CAPSULE. Everyone who has a breast implant (hopefully two) has a matching scar capsule. Fortunately, most women never even know it’s there. Only about 10% of women will ever have any signs of shrinkage or tightening of the scar capsule, and mostly the signs are mild . If you have noticed that your implants started out perfect but now one of them looks tighter or higher up on your chest, you’re one of the 10%. Other mild symptoms can be firmness of one side compared to the other, or one side that doesn’t move as easily or naturally than the other. If these or other imperfections in your result are noticeable or bothersome to you, contact your surgeon. I’ll be happy to see you even if I didn’t put your implants in. (Many of the scar capsules I fix had their implants elsewhere)
How do you fix it?
Usually mild capsule contracture problems are solved in the office. We can offer mild or significant sedation (depending on your personality and wishes) to allow the actual surgery to be performed with a local anesthetic. The scar tissue itself is released like the slits you make when sectioning a grapefruit, allowing the scar pocket to relax and freeing your implant to its original condition. Usually women can return to sedentary jobs as early as the next day. Talk to us to find out if this will work for you.
Is it true that you can take unwanted fat from your hips and turn it into bigger breast size?
The answer is a stunning yes. But not so fast… there are several caveats. For one, there is a limit to how much fat can be transferred at any one time and probably a limit on the absolute size of the finished breast. It may take several incremental surgeries to get the change , and there may be changes in your mammogram.
So how come we’re just hearing about this now? Fat transfer has been around for a long time, but the very first attempts done in the infancy of the liposuction era were a disaster. The ASPS (the national society for real plastic surgeons) actually banned the procedure. Once they did that it became medico legally almost impossible for legitimate plastic surgeons to perform the procedure. In recent years, the rules have been gradually bent to allow for fat grafting to become a standard part of the breast reconstruction armamentarium. In 2012 the ban was quietly lifted and the procedure is gradually gaining acceptance.
The procedure can be done in the office, but expect several treatments to enlarge the breast as much as 1 cup size. The good news is that the fat can be placed more or less where you want it. For example, more can be placed in the upper breast with less in the lower . This is commonplace in my practice when fine tuning breast reconstructions to make up for an uneven mastectomy by the general surgeon. The bad news is that unless you are very patient, an augmentation with your own fat may be very limited in size. While most breast implant patients use 300cc or larger implants, fat grafting is probably best for women who wish 75-100cc of increase. The process can be repeated, but you’ll need to wait at least 6-8 weeks between procedures.
Call Dr Zickler’s office to schedule a consult to talk about this in more detail.
#1 How soon can I get my surgery?
Often we are able to schedule surgery dates as early as two weeks after the first consultation. Of course, assuming that your health will permit this and assuming the dates available are compatible with your schedule. For people with much longer surgeries where more operating room time is required, it may require a little more lead time. For people who are waiting insurance prior authorization statements, often there is a 4-6 week lead time through the insurance carrier before we can schedule surgery, so depending on your needs we may be able to get your surgery very quickly. Please leave yourself enough time if you are thinking about getting a procedure so you are not left doing things in a rush. This should be a very careful consideration. Your health is too important to leave to the last minute.
#2 What is the difference between silicone and saline implants?
This is a very deep topic with a great deal of literature and information. The short answer is that saline implants are filled with the same I.V. fluid that you might receive in the hospital, whereas silicone implants are filled with a silicone gel. Some of the silicone gel is non-cohesive. Recently the “gummy bear” implants are now filled with a cohesive gel which should theoretically have less risk of migration if there should be a rupture, leak or deflation of the implant. In general, saline implants have the disadvantage of perhaps showing rippling or dimpling in thin patients who receive large implants more so than silicone implants would. Silicone implants have the disadvantage of requiring an MRI scan to check on rupture, leak and deflation. This is recommended by the manufacturer at every 2-3 years after implantation. Saline implants tend to be somewhat less expensive on the front end and have much less cost if they need to be removed for rupture or deflation. Silicone implants are often more expensive at the time of the first surgery, require MRI surveillance and can have more significant problems if thy do rupture requiring a more extensive operation to remove not only the silicone gel but often the scar capsule that contains it. Silicone implants however are less likely to rupture, leak and deflate than the saline implants. This is a complicated issue and will be addressed soon in its own page in the web site.
#3 How do I know if I need Botox and fillers or do I need a “real” facelift?
In general, botulinum toxin and the currently available dermal fillers are excellent ways to camouflage and treat fine lines and wrinkles in the face. Botulinum toxin works by weakening the underlying muscles of animation in your face. Such lines as the vertical 11’s between the eyebrows are caused by contraction of the corrugator muscles. By weakening these muscles in people with good elasticity and no fixed lines in the skin you may have complete resolution with botulinum toxin. However, if this has persisted for a long time and the skin itself becomes redundant or there is significant brow ptosis from the normal aging process and overuse of the corrugators and the forehead skin and frontalis muscles no longer appropriately support the brow in good position, it may be that Botox is not a good solution even for the vertical 11 lines that it is FDA approved for. It may be that the ideal correction for this problem in someone with brow ptosis and loss of muscle tone in the frontalis muscle and redundant skin of the forehead is an appropriately performed brow lift which is a real surgical procedure. The surgery is meant to restore normal anatomic relationships and rebalance the position of the brows and in so doing eliminate the vertical 11’s. Generally surgical procedures are longer lasting in their effects and much more definitive in fixing the problem. A careful analysis in our office can help you decide which is right for you. Just like this discussion with the vertical 11’s, many other of the lines and imperfections in the face can be either camouflaged with dermal fillers or restored with surgical procedures such as facelift or autologous fat transfer. The short answer to our FAQ is that fillers and Botox often camouflage minor problems in youthful skin of good quality, whereas surgical techniques are necessary to restore significant changes in aging or weight loss. As always, a careful consultation in our office will be your best guideline no matter which therapy you end up choosing.
#4 Do I need my implants replaced after 10 years?
No. Melissa has heard this question a surprising number of times from women who have been told by other doctors that they should have their implants replaced. I am not sure where this idea came from, but the answer is “no.” If you have saline implants the accumulative rupture, leak and deflation rate risk is about 1% for every year you have had your implants so your risk over the next 10 years of having an implant rupture is less than 10%. That means 90% of women who have implants for 10 years do not have any rupture, leak or deflation. If you are happy with your implants there is no need to have them routinely replaced just because of a given time interval. The implants usually fail by a mechanism known as “fold flaw” which is somewhat random in its distribution. If you are happy with your implants, there is no rippling, dimpling or capsule contracture problems, then leave well enough alone and enjoy them. With a saline implant, if there is a rupture, leak or a problem with the implant, you will know. It will be obvious and it wil go flat. At that point it is reasonable to have your implant replaced. Different manufacturers at different times have had different warranty policies but probably you will get your implants replaced free of charge if you have either Mentor or Allergan (McGhan) implants.
If you have silicone implants, this is a different matter. You do not necessarily need them replaced after 10 years. Their rupture, leak and deflation rate is even lower than for saline implants. However, the implant manufacturers recommend an MRI three years after your implants and every two years after that to worry about a condition called “silent rupture.” It is important to know if your silicone implant is ruptured or not before you have symptoms. This is another topic for discussion. If you have had an MRI and the implant is intact then, again, there is no need to routine replace your implant just because of a given time interval. The reason to replace your implant is if you are in some way dissatisfied with the implant or your body scar capsule around it.
If you have any questions about plastic surgery, or related topics and want them addressed in a future blog post, leave a comment .
YOUR FIRST VISIT
Your first office visit is a chance for you to get to know our wonderful staff and to meet your doctor. Dr Zickler will spend a great deal of time with you one on one. We need to get some information from you about your desires and your goals. We will also need to know about your medical history enough so that we can decide if what you want is safe for your health and we will also want to give you a great deal of information about whatever procedure you are looking into. For the sake of example, we will talk about breast augmentation.
When you first come in you will meet the receptionist. If you can let Melissa know that you are here, she will give you a copy of our preoperative information sheet. This is also available on the website. It will be very helpful if you complete it before you come in. It will save you a great deal of time and allow you to do this in the privacy of your own home at your leisure. In any event, this gets some very basic information down such as allergies and your name and address. We will also want to get some information from you about how you would like to be contacted. We need to know whether we can leave messages on answering machines or cell phones or whether you would like our communication with you to be more private and we should not leave messages. Because these things will be best taken care of before your consultation , plan to get to your visit early, about 15 minutes ahead of the scheduled appointment. You may be used to other doctors’ offices where they are always late and delayed and you spend a long time in the waiting room. Typically with Dr. Zickler’s patients we try to keep the wait less than 15 minutes. It is very seldom that we get behind, but this is a surgical practice and sometimes we are doing surgery and we may run over the time estimate for any particular patient. In any event, we have lots of magazines to look at but you may want to bring something with you in case there is a need to pass a short amount of time.
If during your consultation you feel that you would like to go ahead and schedule your surgery, we can take care of that at the visit. You will receive a very detailed written price quote from our Business Office, whch will outline the cost of the implants, the cost of the Surgery Center, what a likely anesthesia charge will be as well as Dr. Zickler’s fee for the procedure. Although we try to be as accurate as we can and get up to date quotes from the Surgery Center and Anesthesia on the day of your visit, unfortunately we do not have any control over their pricing. After you have received all of your information and pricing, you will also be given some written material to take home that should summarize all that we have talked about during our office visit. All questions are welcome and once you think that you have an adequate understanding of all the issues involved and would like to schedule surgery we will be available to do that either at your first consultation or at your convenience over the telephone. As yet, we are not able to do actual surgical scheduling over the Internet because of the involvement of the Surgery Center. At present we are not charging for our consultations for surgery that is not covered by insurance carriers so you can literally feel free to visit us after you have been seen by another plastic surgeon. Only by comparison will you see how much more we have to offer. We look forward to meeting you.
Cosmetic Surgery Associates has just upgraded its website. This finally allows us to have photos and blogs. Please check back often as I hope to have the blog take on a life of its own. Please send in any topics you would like to see discussed in a blog format. I hope to keep the posts informative and hopefully interesting. As I get better at this I’ll be better able to include pictures,images, icons and links, but for the first few bear with me as they’re likely to be a bit “texty”.