AUGMENTING, REDUCING, LIFTING, RECONSTRUCTING
BREAST AUGMENTATION
SILICONE VALLEY: WHAT'S IN A CLEAVAGE'S NICKNAME
 Silicone technology really revolutionized breast surgery. It started in the sixties with a injectable liquid form only, that got quickly abandoned because of problems of migration of the liquid gel. When a silicone polymere could be constructed to hold the liquid gel in place, the ideal seemed to have been found. There finally was a safe substance that was tolerated by the body (medically inert) that felt like normal breast tissue and had a similar specific weight. The French Dr Arion pioneered the technology, which got quickly copied by the competition in the US at first and later also in Ireland and Brazil. At a given point in the nineties some doubt was raised in the USA and the American Food and Drugs Administration (FDA) temporarily forbid its use in a ill-advised move that currently has been reversed. To date all breast implants consist of an outer envelope of silicone polymere that surround a viscous gel of semi-liquid silicone. However, great variety exist between manufacturers in the texture of the surface, additional layers of coverage and the shape and viscosity of the contents. This means that the modern surgeon has an infinite combination of implant types and operation techniques at his disposal in order to suit the individual patient best. |
COHESIVE GEL FILLING
THE CONSENSUS
 currently is that it is safer to use a cohesive silicone gel as a filling for all breast implants. This means that in the unlikely event of envelope failure, the contents can be removed in its entirety. In the past with the liquid gels this posed a problem as the gel tended to penetrate the surrounding tissues and was very messy to remove even partially. The shape of the implant than depends on the setting of the gel in the mould in conjunction with the envelope. A myriad of shapes and sizes are available now, depending on the manufacturers. Some ranges are relatively straightforward, others can be very complicated to assist in fitting, often to the smallest detail, the patient's requirements of size shape and symmetry. |
CAPSULAR CONTRACTURE
THE DREADED COMPLICATION
 It is a propensity of animal tissue to develop a layer of connective tissue around an ingrowing foreign object. In the case of silicone implants, the initial trials with smooth shelled prosthesis led to very awkward, often extremely painful and disfiguring, contracture of this "capsule" surrounding the implant. I was personally asked to review this incidence in 1989 in Whiston Hospital near Liverpool (UK). I arrived in no less than 80% capsular contracture in a series of 30 patients after one year only. To my mind, the subglandular technique of implanting smooth shelled silicone implants, therefore, was (and still is) unacceptable surgical practice. Thankfully in that same year, the textured prosthesis found general acceptance and consequently the capsular contracture rate decimated, salvaging the concept of cosmetic breast augmentation in the long run. |
THE ENVELOPE SURFACE
KEY TO SOFTENING THE CAPSULAR REACTION
 By adding a microscopic texture to the polymerization techniques of the silicone envelopes, the myofibroblasts, the cells that produce the collagen and cause the capsule to contract, are manipulated to temper their activity. If you comparte the two histological slides of capsules you can see a thick well organized capsule above and a more fragmented friendly capsule below. You can also observe some fragments of implant texture in the picture below. |
MICRO POLYURETHANE SURFACING (MPS)
THE REVIVAL OF A PROVEN TECHNIQUE
 A step beyond simply texturing the silicone envelope itself, is to add additional microscopically textured foam on top of it. This reduces the capsular contracture rate to close to zero after 10 years, even in pre-pectoral implants. This opens some particular possibilities in surgical approach, impossible with the silicone-only prosthesis. The technique has been around for many years but has recently been refined and re-popularized as a European spin-off of South American manufacturing. A wider choice of shapes and sizes is available, even surpassing the 1000cc, and further progress is being made by combining different viscosity gels in one implant. MPS implants are now the first choice in the treatment of capsular contracture, wether after cosmetic augmentation or after reconstructive surgery after breast amputation. |
