Saline and silicone gel are very different filler materials with different properties. Saline is called a non-coherent filler. A non-coherent filler does not resist a change in shape, whereas a coherent filler like silicone gel does resist a change in shape. In other words, if saline is placed into a round container and suddenly that container changes shape to square, the saline will quickly flow and assume the square shape. Not so with silicone. It will stay round, at least for a while, until it slowly moves to take the new shape of the square container.
Implants are silicone shells filled with either saline (salt water) or silicone gel (approved by the FDA November, 2006). There are two primary types of fillers used in breast implants: saline filled and silicone gel filled implants. Saline implants have a silicone shell filled with sterile saline (salt water) liquid. Silicone gel implants have a silicone shell filled with a viscous (cohesive) silicone gel. Saline implants are firmer than silicone gel implants. Silicone gel implants better resemble the texture and feel of natural breast tissue. Not all silicone gel implants are the same. Silicone can vary in its physical properties. Some implants are softer than others. Some are firmer, but hold their shape better (“Gummy” implants). You can read more about the different implants types here. Both implant types are very safe, and each offers its own specific advantages. I will help you decide which kind is right for you.
Saline Implants
I want to get this one out of the way. Saline implants are very firm, far more so than silicone gel. Saline implants have far more rippling associated with them than do silicone gel filled implants. Some people request them because they believe that they are more “natural.” Saline implants have a silicone shell (envelope, bag) just like all silicone gel filled implants do, so what is so natural about that? The next thing I hear from those requesting them is that they are “safer.” If a saline implant gets a leak, or ruptures, it is true that the saline will be absorbed by your body and you will excrete it. Your breast will deflate in a couple of days. Now, the soft tissue envelope (your breast) will begin to contract against this empty space so it is advisable to fill it with another implant fairly soon (a few weeks) before the breast contracts so much that it will be difficult to produce a similar appearing breast with a replacement implant, even of the same style and size as the implant you had prior to rupture.
These same people then express concern that if a silicone gel implant leaks, the gel will travel all over your body. The reality is that is not the case at all. Here is why: Whenever a foreign body such as a pacemaker, artificial joint, or breast implant is inserted into your body, the body responds to it by creating a scar tissue capsule around the foreign body, much like an oyster creates a pearl around a piece of sand placed inside. The scar capsule typically forms around a breast implant in about three weeks. Should a silicone gel filled implant rupture, and the gel comes out of the implant shell, this gel will remain trapped inside the pre-existing scar tissue capsule. The gel has no opportunity to travel anywhere. Silicone is inert anyway, which means that it will not react nor cause harm to the body and vice-versa. Lastly, at surgery, any silicone gel that is loose in the implant pocket is actually very easy to remove.
Another disadvantage of saline implants is that saline implants have a valve used to fill them during surgery (they arrive deflated from the manufacturer), which is another potential point of failure (leakage) not found in silicone gel implants, which arrive pre-filled from the manufacturer. My own personal feeling about them – in the vast majority of cases, breasts augmented with saline implants just do not feel natural. The exception would be a young person with at least a full B cup to start with good quality tissue. In these cases, saline implants will often produce a satisfactory result, but still never feel as soft and natural as the breast would with a silicone gel filled implant. And, think about this – as the breast ages, maybe following pregnancy and breast feeding, the breast tissues now atrophies. That same saline implant that gave an acceptable result will now not look and feel so natural anymore. So, you need to think about the future as well when selecting an implant. Am I biased towards silicone gel implants – absolutely. Having performed thousands of breast augmentations, I believe that there is no comparison between saline and silicone implants. That is why both my daughters have silicone gel implants, not saline. I removed my wife's saline implants and replaced them with silicone gel filled implants. This is just my opinion, but I have a vast amount of patients who will agree with me.
The Ideal structured implant available that is filled with saline but has a series of baffles inside – like a series of implant shells one surrounding another. This reminds me of the Russian Matryoshka doll. It has not one, but two valves (double the point of failure). The purpose of the baffles is to control the flow of saline inside the implant to give it a similar feel to that of a silicone implant, but without any concern for loose silicone if ruptured. While this implant is superior in feel to that of a conventional saline implant, I do not find it to be as close to silicone as perhaps its manufacturer would like me to think it is. This implant only comes in one variety, and therefore there is no ability to customize the implant characteristics to the specific breast tissue characteristics and patient preferences like one can do with silicone gel implant. While I am sure you can achieve a reasonable result with this implant, I do not believe (my opinion here) that the results will be the same as with a silicone gel implant. The Ideal implant manufacturer went bankrupt. Another company has received FDA approval to market them. I do not personally recommend this or any other saline breast implant.
So, in summary, in my humble opinion, considering today’s choices in silicone gel implants, I do not believe that saline filled implants are optimal for anyone except a person who wants implants but is petrified of having a silicone gel filled implant inside their body. And that is an unjustified fear, but then again, you can only educate someone to try to resolve their issues. Should those fears persist, I know of no way to make them disappear. That is my only indication for a saline implant – unjustified fear of silicone.
Silicone Implants
I am going to include a little bit of the history of silicone gel implants to provide context in the evolution of my practice up to my current recommendations and preferences in breast implants.
Silicone gel-filled implants provide a much more natural feel to the breast, and are the implant choice for the vast majority (99%) of my patients. In November 2006, after fifteen years of intensive study by many researchers, the U.S. Food and Drug Administration (FDA) had re-approved silicone breast implants for breast augmentation surgery. I am proud to offer patients the option of silicone gel-filled breast implants, since they yield a much softer and more natural feeling breast than when saline-filled breast implants are chosen.
A silicone implant feels much closer to human breast tissue, whereas a saline implant is firmer than breast tissue. Due to the cohesive nature of silicone gel, such an implant has far less rippling and wrinkling than does a saline implant. This is especially important for women with thin tissue, as irregularities in the implant contour will be painfully obvious with respect to the look and feel of the augmented breast. Remember this important concept for later: the more tissue you can put in front of an implant, the less visible and palpable the implant will be.
Although this will be discussed in far greater detail later on, I just want to make clear that there are many different formulations of silicone, each one with its own unique, specific mechanical properties. Some are softer than others, some preserve shape better than others, some resemble a teardrop shape and others more of a round shape. This will all be addressed later on.
OK, so now we have silicone gel filled breast implants? What is next? How do we differentiate between all the available choices of implants. Here are some of the things that we need to consider:
- Silicone gel formulation: Some silicone gels are firmer, some softer, some hold their shape better than others. Most manufacturers of silicone gel implants offer more than one choice.
- Shape: round or teardrop? Even that can get complicated because some teardrop implants are of a fixed shape - and some are round and assume a teardrop shape only when vertical - the position they will be in when the woman is standing upright.
- Surface: Smooth, SilkSurface or Macrotextured?
- Profile: Low, Moderate, High or Extra-high? What are the differences and when would you recommend a particular choice?
The next section will address all this in great detail.
The implants that I have preferred are discussed in the subsequent section: Silicone Gel Breast Implants – Options
Saline, Silicone and Safety
In 1991, due to unfounded concerns that silicone breast implants were responsible for certain autoimmune diseases such as rheumatoid arthritis, lupus and scleroderma, the FDA director, David Kessler, MD (a pediatrician), created a moratorium on silicone breast implants pending further study. What this meant was that silicone gel filled breast implants would not be available in the United States for general use in women except under special organized multicenter investigational studies. The use of these implants did continue, however, in other parts of the world. In November, 2006, the FDA gave clearance to the use of silicone gel filled implants. Silicone breast implants became the most studied medical devices in history. The results of these studies concluded that silicone breast implants are safe and are not related to breast cancer or connective tissue disorders.
The internet contains a plethora of information about both saline and silicone breast implants, and connections between each of them and many different diseases. This collection of symptoms and medical disorders thought to be attributed to breast implants has been termed Breast Implant Illness or "BII." This is an emotionally charged issue and there are many women who believe that their implants have made them ill. However, anecdotal descriptions of individual cases, "junk science" (medical studies not conducted via approved scientific method) and other opinions spread across the internet do not provide clarity on this issue.
For the purpose of this discussion, I will state that current scientific studies do not support a connection between saline and silicone breast implants and "breast implant illness." I have a more detailed discussion of this topic, complete with current references from peer reviewed scientific publications, elsewhere on this website here.
There is an association between textured surface implants (both saline and silicone gel filled) and a rare, low grade malignancy called Anaplastic Large Cell Lymphoma (ALCL). This is not breast cancer, but rather an easily curable, low grade malignancy of the natural scar tissue that forms around every breast implant or implantable device inside the body. At this point, I am NOT using textured implants; I only use smooth or "silk surface" (Motiva) implants, so this is not a concern. There have been no cases of ALCL attributed to either type of breast implants. You can read more about ALCL here.
Can One Silicone Gel Implant Be Safer That Others?
The Motiva implants received FDA approval on September 26, 2024. The MOTIVA FDA US Clinical Trial is a ten year study where data is collected from multiple study sites (including my own) annually and submitted to the FDA. I have written an interesting article that looks at differences in the safety profile of silicone gel implants from all four FDA approved manufacturers. This article can be viewed here:
There will be a great deal more information on the new Motiva implant in subsequent chapters of this guide.
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Next Topic: How do silicone gels differ? »
Topics - What Implant Type Do I Need
Sections – Five Key Decisions You Need To Make
Chapters – Breast Augmentation Guide
- Intro to Breast Augmentation
- Motiva Breast Implants
- Five key decisions you need to make
- One-Day Recovery Breast Augmentation
- Anesthesia – General, Sedation or Local?
- Breast Lift (Mastopexy) with/without Implants or Fat
- What else should I know about breast augmentation?
- Important Things to Consider When You Decide to Move Forward With Breast Augmentation
- Revision of breast augmentation
- ALCL and Breast Implant Illness
