What to Know About Breast Implants

Doctor’s Note

Welcome to Plain Talk About Plastic Surgery, a podcast that educates you about all things relating to plastic surgery procedures and operations, with down-to earth and honest information.

I’m your host, Dr. Elizabeth Kerner.  While you listen, I hope you’ll think of me as your sister, the plastic surgeon, who will tell you like it really is.

I have been in practice in Plano TX, a northern suburb of Dallas, for over 30 years.  I am an American Board of Plastic Surgery certified plastic surgeon, and have been a member of both the American Society of Plastic Surgeons and the The Aesthetic Society.

My practice is predominantly cosmetic surgery, doing about 80% cosmetic surgery and 20% reconstructive surgery.

I am a past president of the Texas Society of Plastic Surgeons.  I was also the first female president of the hospital medical staff at Texas Health Presbyterian Hospital Plano, where we have 1,400 doctors.

I am a member of the Texas Medical Association, and the Dallas County Medical Society. I have been on many leadership committees and boards over the years.

Each episode of Plain Talk About Plastic Surgery will focus on one area of plastic surgery in depth, discussing the anatomy, the operative technique, risks, potential complications, and most importantly, who would be a good candidate and who would not be a good candidate.

Useful Links

If you enjoyed this episode, you might also like:

• Learn about Breast Lift
• Learn about Breast Reduction
• Learn more about Breast Reconstruction
• Learn about Revision of Breast Surgery
• Learn about Breast Augmentation
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Episode Transcript

Introduction

“I’m Dr. Elizabeth Kerner, and welcome to “Plain Talk About Plastic Surgery”, your source for all information about plastic surgery procedures and operations from a real live plastic surgeon, who is me!

I have been in practice for 32 years and am here to give you honest, down to Earth advice. If you think of it, as if you had a sister who is a plastic surgeon, this is what she would be telling you about questions you might have about plastic surgery.

Today, we are going to discuss breast implants.

As probably everybody in the United States knows, the history of breast implants has had a circuitous and somewhat tormented course to bring us to today’s implants that are available and are considered safe, and are on the market. Not everyone agrees about the safety of silicone or saline breast implants, and I’m going to touch on what I know and then what my experience has shown me over the years.

I do not plan to talk about breast implant associated acute large cell lymphoma. That’s a huge topic and the data on this is changing almost on a daily basis. I hope in another couple of weeks, I can do a podcast and summarize where we are today, knowing full well that this is most likely going to change data-wise in another couple of months.

Today we’re just going to focus on how implants came to be and what they are like now.

The Invention of Breast Implants

Way back in 1961, two plastic surgeons at Baylor College of Medicine in Houston, Dr. Frank Giro and Dr. Thomas Cronin, were brainstorming how they could come up with an implant.

As legend would have it, Dr. Giro happened to be feeling a bag of blood and thought, “Oh, we could put it in a blood bag container”, and “what material could we use?” And they came up with silicone, and lo and behold, with the help of Dow Corning Corporation, they created the first silicone breast implant.

A very interesting tidbit is that I knew Dr. Giro when I was there at Baylor College of Medicine as a medical student. He was a professor of plastic surgery. Very nice man and very good surgeon, and I had him operate on my wrist to get rid of a ganglion cyst. So, I feel a little bit of a kinship.

And then the second interesting thing is Dr. Thomas Cronin, who was his co-partner and arguably, probably the more scientific of the two, is well known in the Texas Society of Plastic Surgery circles because of his contributions to medical science and getting the Texas Society of Plastic Surgeons up off the ground and going.

Every year, we have an annual meeting. The highest scientific award that is presented, which is now to the residents, because we have a huge number of residents that come in and give papers, is called the Cronin Award.

His son, Dr. Ernest Cronin, is a plastic surgeon in Houston at the University of Houston. He was president of the Texas Society of Plastic Surgeons a few years after I was. I was in 2000.

So all of this is just a tiny bit of tales and legends that I have grown up with, if you will.

Doctors Giro and Cronin created a little silicone implant, and they implanted it into a dog. I believe her name was Esmeralda. Esmeralda did really well with having the silicone implant in under her skin. There was no evidence of rejection, but she did decide to chew her stitches out, so they took the implant out. When they looked at the little pocket where the implant had been, they didn’t see any problems and concluded (with unfortunately, just a few weeks test in a dog) that silicone implants would probably be safe for women.

So they convinced a patient of theirs, in 1962, Timmie Jean Lindsey, who was a factory worker and a mother of six, who really came in to get a tattoo off and to get her ears pinned back, that she should be the first breast implant recipient.

Evidently, they pushed pretty hard, and what she really wanted was to get her ears pin back. And so she said, “sure, you can go ahead and put these implants in me.” There is an interview floating around the internet, if you look, with Timmie Jean, I think at the 50 year anniversary. She still has her original implants. I am sure they’re absolutely hard as rock, but she was pretty thrilled about it.

Popularity of Early Breast Implants Soars… and so do the Problems

So then implants took off and there were multiple types of implants. The type of envelope that they were in, the silicone formula for the internal gel saline implants came around in about the late 1960s. But they seemed to have a lot problems originally with high leakage from the valve because you had to fill them in the operating room and they did slosh quite a bit.

There was an implant called the Ivalon sponge, which was like a big wad of polyurethane foam rubber that would be put in. I had the opportunity to take several of those out very early in my practice and they were absolutely awful. If you ever go online and you see pictures of implants that they swear have mold and cruddy things coming out of them, I think those were probably the very old Ivalon sponges.

In 1976, the FDA finally decided to regulate the safety of medical apparatuses, and silicone breast implants fell under that but were given a grandfather out because they’d been in use for about 15 years at that point.

In 1977, the first lawsuits started because of increasing firmness around the implants, because of rupture.

And go forward, go forward, go forward: 1988. Now the implants are a Class III category, which means they have to prove their safety. Plastic surgeons and implant manufacturers realized that they had exceedingly little data in terms of safety in the human female breast.

Of course, the flip side to that is they didn’t have data that it wasn’t safe. What we knew at the time and still continue to hold out, as I would say, probably the two most negative things about implants is that they will not last forever, and women may, and frequently do, develop hard scarring around the implant, what’s called a capsular contracture.

By 1990, when the episode with Connie Chung came out, then lawsuits were filed just all over the country; actually really probably all over the world, eventually leading to the collapse of Dow Corning, and many lawyers got very rich in this time.

Unfortunately, in the courts, what was being offered up as expert testimony is now widely considered to be junk science. Plaintiff’s attorneys would say just about anything, Dow Corning kept settling, settling, settling, and then eventually there was a large settlement and all of the Dow Corning implants went away.

Also at that time, an implant that was in significant use was called the polyurethane implant, or it was manufactured as Même or Replicon. I used this a lot. It had an external coating that was textured, and when you would put the implant in, the body would integrate into the shell of the implant.

So, we’ll go back just a little bit to anatomy. When an implant is placed into the breast, either under the breast or under the muscle, your body is going to make a little layer of scar tissue around it.

That’s called the capsule. Everybody makes a capsule. As long as you have a functioning immune system, you’re going to make a capsule.

What happens to many breast implants, though, is as they fail, the silicone will begin to leak through the outer envelope. It’s captured by the scar tissue around it. That sets up the body’s immune response, and now you start getting more and more firmness as the body sends more scar tissue in.

And the old implants that we would take out, because there were significant incidents of silicone leakage and rupture, the inside of the capsule (remember that’s the shell around the implant) would really look like the inside of a bad water pipe. It would just be plainly calcified.

And of course, if that started to develop and the implant hadn’t ruptured by the time your nice smooth implant is rubbing on this calcified shell internally, then of course it’s going to completely rupture or bust.

So around 1992 or 1993, silicone implants were only approved for use in women who needed reconstruction, which I always thought was rather oxymoronic.

Basically, you’re saying “if you’re a healthy woman, we don’t know if it’s safe enough for you to have, but if you’re a woman with breast cancer, well, what the heck? You’ve already got breast cancer. I guess you can get a silicone implant.” That just always absolutely rubbed me the wrong way.

Silicone Breast Implants Begin Making Strides to Improve Quality and Safety

But about 14 years later, manufacturers came up with enough safety data to satisfy the FDA that implants really are safe with the two known caveats: they don’t last forever, and women will develop capsular contracture around the implants.

So let’s talk about what implants are available right now. You still have silicone options and you have saline options.

I’m going to briefly discuss old silicone. So, generally a smooth outer envelope, and a liquidy silicone gel internally. The old polyurethane implants had a textured coating that would help to keep the implant in position and reduce the encapsulation. But that company went out of business because it turned out that they had falsified their data (another big black eye on the silicone industry).

But the remaining manufacturers realized that despite the fact that the data had been falsified showing the original safety, the track record of those implants showed that women did not develop nearly as much encapsulation around that texturization of the implant, the polyurethane foam. So they have tried to simulate that texturization on more current implants, and it really seemed to be working and became really quite popular, I would say, in the mid 2000s to do those.

But then along came the development of the acute large cell lymphoma in response to the textured portion of the implant. So now all texturization is pretty much gone. Mentor still has a textured implant, but I don’t think it’ll be on the market for terribly long.

Let’s go back to silicone. So right now, what we have are forms of cohesive silicone. The most formed is the fully form-stable cohesive gel, or what women and certainly the media’ called “the gummy bear”.

I don’t think it really feels quite so gummy-ish. It’s a little bit more like a softer foam rubber, if you will. And when you cut that implant, there is a solid gel that you cut through. It’s like a block of Jell-O with just a tiny bit of stickiness to it.

I have cut some in half and had them sit in a bag for a very long time, and there are not really any grease rings that occur on the paper towel like it used to be with the old implants, where the silicone was coming out. It doesn’t really even stick to your finger.

I have had the occasion to only take a few of these out. Very different removal than regular old silicone where the sticky gel was everywhere and you had to do a lot of removal of breast tissue and sometimes muscle just trying to get the silicone out. These implants really just sort of wipe out. I tell my patients it’s a lot like if you took unflavored gelatin and hydrated it. It’s that same consistency.

The negative to these is that in some women who are thin, they are I think just a little bit too formed, and a little bit too foam-rubbery, if you will.

But if you’re looking for an implant that has more shape and more projection and you feel like your breast is way too soft and you want it to be slightly firmer (though these aren’t going to be hard) then this would be a great implant.

They also have the old silicone gel type implants, but I don’t offer them because when they rupture, then you’re going to have to clean out all the silicone and that’s a mess.

And then the intermediate step is called a Soft Touch, which is like a soft brie, if you will. So it’s not fresh out of the refrigerator, which would be like the cohesive one, but has sat out on your counter for a little while. So that when you cut that, again, there’s no flowing, sticky gel. It doesn’t flow. It looks like the cohesive, but it’s just got a little bit more stick to your finger when you touch the gel.

I have had no patients with a ruptured implant of this type, so I unfortunately have no experience to tell you how hard it is to take out. But if someone doesn’t like the firmness of the fully cohesive, I think the Soft Touch is a good alternative.

So those are the two silicone implants that I offer in my office, and they both come from Allergan. I do like Allergan products better. There’s also Mentor and Sientra. I don’t use them, so I don’t really have any track record with them that I can tell you about safety or problems.

Saline Implants Up the Game for Breast Implant Safety

Saline implants use the same outer envelope as the silicone. So, shells are manufactured the same way, and then there’s a little valve, and in the operating room (with a little tube that’s connected to an IV) we can fill it with saline and put it into the body.

The nice thing about saline is you will be inflated until your implant fails. Unlike silicone where you could have a rupture, especially with the old ones, and you might not know.

With saline, if you get a hole in it, that salt water is coming out. It’s just salt water. There’s absolutely no risk to you, and you will physically deflate. It could take a couple of days, which is normal, or it could take a few weeks, but you’re going to go flat and pretty much anybody could look at it and know.

Because there’s no silicone to deal with, removal of a deflated saline implant is a little bit of a tire change. We just go in, take the one out, put a new one in, inflate it, sew you up, and you’re on your way.

Of course, all of this is done in the operating room under anesthesia for sterility because implant infections would be huge if we just did them in the office. But it’s way easier than the initial augmentation and of course, much less expensive.

Drawbacks of saline are: the regular saline is just a round bag of saline, so it tends to have more wrinkling and have a sloshy sensation to it. If you think about a waterbed from the 1970s, you’d sit on it and this big wave would go across the waterbed, and that’s why they weren’t very popular after a while.

Then the waterbed got baffled, so they put internal walling within it so that it’s still a waterbed, but because the water is contained in chambers, it feels more like a real mattress.

My Favorite Breast Implant: the Ideal Implant

Well, Dr. Hamas here in Dallas did the same thing with the saline implant. He baffled with the implant. He put multiple shells within the outer shell so that the saline is contained within separate compartments.

When you feel it, there’s very little wrinkling and there’s no sloshing. I love the Ideal Implant because I think it’s got the safety of a regular saline implant… well, I don’t think I know it has the safety of a regular saline implant.

Again, when it fails, you’re going to deflate. Because there’s multiple compartment, you’re not going to go all the way down, but it’ll deflate enough to be able to tell. It’s just saltwater, so there’s no concern about silicone, and I think it feels very natural.

My patients that I’ve done the Soft Touch silicone, remember, that’s the intermediate soft brie one, versus the Ideal Implant, I have a really hard time telling which implant I’ve put in. I have put the Ideal Implant in very, very thin women and really haven’t had a wrinkle issue at all.

Both implants (both silicone and saline) can encapsulate, meaning the scar tissue around it can become firmer. Although with saline, the percentages are way less than they are with silicone.

Ideal Implant, if you go to their website, will list out percentages of encapsulation by year and whether it’s a primary augmentation or re-augmentation versus various silicone, and the numbers are pretty striking.

So that’s where we are right now. You’ve got in my office two types of silicone to use and one saline. I don’t offer the older saline because I think it’s too wrinkly and sloshy.

They are all safe. They will all eventually fail. So if you get an implant, you have to figure sometime in 15 to 25 years, your implant is going to fail. So you’re going to need to have another operation to remove it and either put a new one in or just take it out or do a lift; those would be all the options that you’d have.

You do have to have regular mammograms. Typically, if you listen to my breast augmentation podcast episode, I do put these underneath of the muscle, so mammography is not an issue with it.

Final Notes on Breast Implants

Let me think, I can’t think of much else to tell you.

There are interesting articles out on the internet about the history of breast implants. If you’re quite interested in that, please go out and look at it. Remember, when you’re looking at data, you cannot compare the old implants to the new implants. The composition of the implant; the safety range or profile of the implant; encapsulation; and deflation or rupture; leakage are all completely different with these new fifth generation implants as they were with the old ones.

And to that I say, “That’s wonderful news! Thank you so much!” Because the old implants were not that great.

Conclusion

That’s it for today’s podcast all about the history of and currently available breast implants. You can find lots more information about this out on the internet. But again, please be careful what you’re looking at because the old implant styles and risks and complications are very different from the new ones.

We also have information on my website, www.drkerner.com, that’s d-r-k-e-r-n-e-r.com. And there are before and after pictures there as well.

If you are interested in implants, I encourage you to come in and let me discuss this with you in person. The topic of the history of breast implants and what they are like now is a bit more lengthy than what I’ve just done in this podcast. And I do have implants for you to feel and look at. I think that helps to explain the differences a bit more clearly when you actually have an implant that you could put in your hand.

Remember when you look on the internet, data from the ’70s and ’80s and ’90s really doesn’t apply to our new fifth generation implants.

Feel free to contact us if you would like to receive our newsletter where we have regular specials for skin care and Botox and fillers. And then, of course, there are other podcast episodes on the website.

I hope that you have enjoyed listening to this podcast all about breast implants!”

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