Following the fraud that took place a few years ago with PIP prostheses, Health Authorities have multiplied the controls to the manufacturers and requires prior authorization before their commercialization. These breast implants have the consideration or qualification of biometric implants such as knee or hip prostheses, so their health requirements are very high. The material that compose them is object of study and continuous improvement for over than fifty years now.
There are numerous high quality and safe manufacturers that offer a wide range of models that allow the surgeon to choose the best option for each patient according to the technique that will be used to introduce it -axillary, areolar or sub-mammary- the volume or size, the place where the implant will go, its contents, etc. The surgeon will choose the type of prosthesis based on the current breast and the anatomy of the patient and the desired result.
The main objective of modern prostheses is patient safety based on fundamental factors such as:
- Reduce the risk of capsular contracture to the maximum, which has been achieved with rough or textured prostheses.
- The greatest resistance or possible duration. For this, the layers that covers the prostheses have been increased so that in case of breakage the silicone would not spread all over the chest.
One of the decisions that the surgeon must make is the choice of the material that makes up the outer part of the prosthesis that has the form of a pouch in which the liquid is contained. Depending on the outer part or surface of this bag the prostheses are smooth or rough. Each surgeon must decide which is the most appropriate for each breast augmentation operation, but there seems to be a general tendency to opt for the smooth ones when the implant is placed under the muscle and for the rough ones if it is decided to place them above the muscle, but below the gland. The rough or texturized surface achieve a greater adhesion that avoid rotations or unwanted movements of the prosthesis.
Back in the sixties, the first breast augmentation interventions began with numerous problems and side effects, among them capsular contracture or tightening of the scar or layer with which the breast surrounds the prosthesis once implanted. The first prostheses were of smooth surface and the various changes that were tried did not reduce this problem. The first major breakthrough was achieved with a change in its fabrication by which the outer surface was changed, from smooth to uneven surfaces, creating rough or textured prosthesis. From that moment the reduction of the number of capsular contractures was verified and the scar or layer that surrounds the chest was better vascularized and was thinner, with less muscular cells in those of rough surface.
The capsular contractures were reduced but they continued to appear in a high number so it was concluded that their cause was not only on the surface or texture of the implant but could also influence the location of the prosthesis that at that time was normally above the muscle. For this reason the technique was modified to place the prostheses, smooth and rough, in the sub-muscular plane, below the pectoralis major; a more aggressive technique with worse postoperative recovery for the patient but that managed to dramatically reduce the number of capsular contractures and offering an excellent aesthetic result.
Other contraindications appeared with the rough prostheses, but to a much lesser extent, mainly in cases in which the prostheses moved upwards, since they tended to get adhered to the chest making it very difficult to put them back in place gain. To avoid this problem, it’s recommended to not massage the chest until they are firm.
Advantages and disadvantages of both types of implants
Advantages of rough or textured prostheses
- They can be introduced from the three possible pathways (areolar, sub-mammary or axillary) with some ease.
- Its manufacturing quality is very high because they have many layers on the surface and a very well researched roughness with excellent results.
- The layer that covers them has a greater thickness which gives them greater resistance and avoids possible ruptures and provides longer duration.
- They have a good efficacy against rippling.
- Good efficacy against the undesired misplacements due to its good adhesion to the tissues of the chest avoid or reduce those movements.
- Accessible price.
- They do not affect breastfeeding or future mammograms or ultrasound mammograms.
Disadvantages of rough or textured dentures
- Its rate of muscle contraction in natural or sub-glandular placement is not especially reduced. If it’s placed under the muscle, this rate descends, with the disadvantage of a more aggressive surgery.
- They have a higher index of seromas, early or late, than the smooth ones.
- They need a greater cut or incision to be able to introduce them, which makes the areolar surgery more difficult if the patient has a small areola.
- If an infection develops, they don’t very well to antibiotics, since the germs nest best in the roughness of their wrapping.
Advantages of smooth prostheses
- They have a better feel as they are softer.
- They don’t adhere to the surrounding tissues so they have a more natural movement as they accompany the movements of the body.
- They need a smaller incision or cut than the rough ones.
- They have fewer cases of infections and are treated better when they appear.
- They cause fewer cases of seroma after the operation.
Disadvantages of smooth prostheses
- They have a higher rate of movement if the breast bag is too large bending themselves over.
- They should be placed under the muscle, which is a more aggressive technique for the patient.
As a conclusion, it can be stated in a generic way (which should be qualified in each case with each patient) that smooth prostheses are always placed in the sub-muscular area, while the rough or textured prostheses admit this location plus the sub-glandular, and both of them have low risk of encapsulation when placed below the muscle, which is one of the main objectives in this intervention. Many surgeons recommend the rough sub-muscular if the patient’s breast has a good mammary gland.
Other issues to consider
In addition to the choice between smooth or rough prostheses there are other factors that must be taken into account when choosing the prosthesis. These factors are the following and you can consult them with any of the surgeons that you can find in www.bonomedico.es, with years of experience and total guarantee.
It’s not a difficult choice since there are many that offer total security and guarantee and any of them is a good choice. Each surgeon usually works with three or four manufacturers offer excellent results and patients can choose among their models whether they prefer a rough or a smooth one.
It is one of the most important decisions and again it should be the surgeon who decides on the best option for each case. Current manufacturers create their implants with two types of materials that have proven their greatest results: silicone gel and saline serum which characteristics are the following:
- The silicon gel stands out because of its special resistance to possible breakages and cohesiveness, making the prostheses firmer as it rarely moves from its place. Their duration is many years, they remain in perfect condition for a long time, without deforming, and only need annual reviews to check if they have undergone some alteration, which happens unfrequently. They are also very natural to the touch. The risk of rupture is very low (less than 0.01%) and when it occurs it’s usually due to some important trauma such as an accident, but, if happens, the rupture is not a risk. There are models of high cohesion or normal cohesion.
- Saline serum implants are introduced empty and then filled once inside. This form of introduction allows for a smaller incision resulting on a less visible scar. They have an increased risk of rupture but, if they do break, patient doesn’t run any kind of risk as this serum is absorbed by the body without any problem. They are somewhat tougher to the touch.
As for the shape, the patient can choose between round and anatomical
- Round prostheses are used when a higher breast volume is expected. The manufacturers prepare them with a cohesive gel of lower density that allows them to adapt their shape when they change of posture by the action of the gravity, concentrating more amount of gel in the inferior part. Therefore, it modifies its appearance when the patient gets up or down, resulting in a more natural look.
- The anatomical ones are made with a dense gel, more rigid, that doesn’t alter its form with the movements of the patient. The older ones were round in the upper part to give greater volume in the cleavage but they didn’t t offer a very natural result and were used in the cases of reconstruction of the breast after a cancer problem, with the main objective of avoiding ruptures. The current ones have a form of tear or drop of water that present a more natural and anatomical aspect.
The size or volume
There is a very wide offer in this aspect with quantities or volumes starting at 125cc up to 450cc. This is one of the most difficult decisions to make for patients and in which they should avoid following fashions or excesses that may be unnatural. The opinion of the surgeon is essential because with his experience you’d be able to see the anatomical structure of your body and make a better choice that may vary from patient to patient. Some surgeons perform simulations with stuffed bras with different sizes or 3D software to help the decision making process.
Another aspect that should be known to any patient who wants to undergo a breast augmentation are prosthetic insertion techniques. Current surgeons use three major access techniques or pathways that we explain below. In each patient, the surgeon should analyze the characteristics of the breast and its anatomy in order to choose the path that best results can offer. All have advantages and disadvantages:
The areolar surgery is widely used by surgeons since it allows the scar to be placed on the nipple edge, an area with important differences in tone and texture of the skin that allow it to be hidden or concealed very well, remaining totally unnoticed. As a drawback, it should be emphasized that it’s a very difficult technique and even inadvisable with some prosthesis models, especially those with large volume.
The axillary surgery is the least used, and it’s mainly used when the nipple contour is very fine or thin to perform an areolar surgery. The scar is hidden under the arm, very far from the breasts, but the difficulty of this technique is important and cannot be used with all prosthesis models.
Sub-mammary surgery is a very easy way of access, with a simple and safe intervention, that allows the placement of almost all models of existing prostheses. The scar is concealed by the breast itself and is invisible while covered. It is recommended for women with a very small areola or for those who want a large volume. The scar can be visible in certain situations such as recreational activities or sports on the beach with a bikini.
Another factor that influences the choice of type of prosthesis is the place of the breast where the prostheses will be placed and will depend on the anatomy of each patient and the model of implant chosen. Current surgical techniques have increased possibilities and the most used areas are the sub-muscular position, between the pectoralis major muscle and the minor pectoralis, and the retro-glandular position. The first location allows greater mobility to the chest and diminishes some unnatural rounded forms at the top. Less rigidity is achieved and the possibility of a capsular contracture is reduced. As main disadvantage we find that the pectoral muscle should be cut, which leads to a more painful postoperative period for the patient. The retro-glandular position is when it’s placed between the mammary gland and the pectoral muscle and no tissues are cut or injured. It achieves a very natural esthetic result since the implant moves with the own gland. It is not feasible with certain prostheses for patients with a very small gland.
How long do prosthetics last? When should they be changed?
There is a widespread belief in society about the need to change prostheses every ten years. However, this belief is not true and numerous scientific studies show the opposite and only warn periodic reviews to check their state of conservation. There are numerous models of cohesive gel that have no expiration date or duration and their useful life exceeds ten years offering a lifetime anti-rupture guarantee.
What is a capsular contracture?
This was, a few years ago, one of the main problems of breast augmentation, and has its origin in the reaction of the breast to the introduction of the implant. The body surrounds the prosthesis and isolates it through a layer or scar that completely covers it. In some cases, it may become too tight causing deformation. This problem, which was one of the main issues in the 1960s and 1970s, has been reduced with technological advances in the design of prostheses and practically eliminated it with the current developed models.