What type of breast implant is recommended for primary breast augmentation?

Breast Implant Selection for Primary Breast Augmentation

For primary breast augmentation, smooth silicone gel implants are recommended over textured implants due to lower risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) while maintaining excellent aesthetic outcomes and patient satisfaction. 1

Types of Breast Implants Available

• Silicone gel implants (including form-stable "gummy bear" varieties) contain a fixed volume of silicone gel with varying viscosity between manufacturers 1
• Saline-filled implants are inflated with sterile isotonic saline to desired size 1
• Double lumen varieties using both saline and silicone are available 1
• Polyacrylamide gel implants are another option 1
• Implants come with either smooth or textured surfaces 1

Safety Considerations

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

• Most reported cases of BIA-ALCL are associated with textured implants 1
• BIA-ALCL is a rare T-cell lymphoma that typically presents with delayed peri-implant effusion (>1 year after surgery) 1
• Typically occurs 8-10 years following implantation 1
• The FDA has recognized this association since 2011, and in 2019 recommended a boxed warning on breast implant labeling 1

Implant Rupture Considerations

• Saline implant rupture is usually clinically evident as the saline is resorbed by the body, causing noticeable changes in breast contour 1
• Silicone implant rupture may be asymptomatic, especially if intracapsular (contained within the fibrous shell formed around the implant) 1
• FDA recommends initial ultrasound or MRI 5-6 years after implant surgery and then every 2-3 years thereafter for monitoring 1

Evidence Supporting Silicone Implants

• Silicone gel implants are safe and acceptable components of the breast augmentation armamentarium 1
• Advances in gel cross-linking have reduced silicone bleed, and cohesive gel implants are likely to have fewer problems relating to capsular rupture 1
• Modern silicone implants are associated with high patient satisfaction and low complication rates 2
• Highly cohesive silicone maintains its shape within the body through extensive cross-linking, resisting deformation from physiologic forces 2

Implant Shape Considerations

• Both round and anatomical (shaped) implants have their place in breast augmentation 3, 4
• A single surgeon's experience with over 1200 implants showed comparable complication rates between round (11.9%) and anatomical implants (9.0%) 3
• Anatomical devices may offer increased flexibility in some cases but require proper patient selection and surgical technique to minimize rotation risk 4
• The optimal choice should consider patient's physical characteristics, available implant types, patient's desires, and surgeon's experience 3

Surface Texture Considerations

• Textured implants have been associated with higher risk of BIA-ALCL 1
• Each manufacturer uses a proprietary process to create textured surfaces, resulting in different textures between brands 1
• Given the association between textured implants and BIA-ALCL, smooth implants are generally preferred for primary augmentation 1

Implant Selection Approach

• Tissue-based planning systems, which use clinical guidelines to determine optimal patient-specific implant dimensions, have been associated with higher methodological quality in studies and lower reoperation rates 5
• The implant selection should match the patient's breast dimensions and tissue characteristics to optimize outcomes 5
• Proper implant selection requires consideration of the patient's anatomy, desired outcome, and risk factors 3, 5

Pitfalls and Caveats

• Choosing implants solely based on desired cup size without considering breast dimensions may lead to suboptimal outcomes 5
• Ignoring tissue characteristics can increase risk of complications such as rippling, visibility, and malposition 5
• Patients should be fully informed about potential risks including BIA-ALCL, rupture, capsular contracture, and need for long-term monitoring 1
• Implant-based reconstruction may result in unfavorable aesthetic outcomes if post-operative radiation therapy is required 1