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Support for silicone

After renewed FDA approval, implants are winning over women who say remaining health risks are outweighed by appearance

It happens over and over. Dr. Karl Breuing, a plastic and reconstructive surgeon at Brigham and Women's Hospital, offers his patient the choice: a saline implant, which feels much like a water balloon, and a silicone implant, which feels more like a balloon filled with firm Jello.

More often than not, he said, the woman hefts and squeezes each, then holds up the silicone and says, "I want this one."

Despite health concerns about an earlier generation of silicone implants, prominent plastic surgeons say that at least half their breast enlargement patients have been choosing silicone in the weeks since the Food and Drug Administration allowed it back on the general market in mid-November.

"American women now have a choice," said Dr. Foad Nahai , president-elect of the American Society for Aesthetic Plastic Surgery. "Right now, in our practice, it's about 50-50" between saline and silicone, the Atlanta surgeon said. "But when I talk to my European colleagues, it's 90 percent gels."

The FDA banned most silicone implants from the United States in 1992 amid concern that the majority of implants eventually rupture, and leaking silicone could pose serious health dangers ranging from cancer to auto-immune diseases. (The implants were not banned in Europe.) Many implants also caused pain and damage to the breast. Dow Corning, an implant manufacturer, faced so many lawsuits that it went bankrupt and in 1998 offered more than $3 billion to settle them.

But most studies have failed to confirm a significant link between silicone implants and disease, and implant makers have developed new forms of gel that are less like the syrup of old and more like extra-soft Gummy Bears. If the implant shell develops a rip or leak, the new silicone is expected to stay put, much as gelatin does when cut, rather than travel through the body.

Dr. Breuing of Brigham and Women's said that when patients are comparing saline and silicone, he actually pokes a needle into the silicone implant and then wrings it as if it were a wet towel so they can see that nothing comes out. In past decades, silicone became a shocking word to many, but the old oily stuff is gone, he said, and to be frightened of cohesive silicone gel implants these days "is unfounded."

Still, implants, whether silicone or saline, continue to carry considerable risks.

Dr. William LoVerme , chief of plastic surgery at Newton-Wellesley Hospital, condenses the 60-page warning booklets that patients must read before having silicone implant surgery down to this: "If you're going to have implants put into your body, over the next five years there's a 20 percent chance that, for some reason or another, you may need another operation on the breast."

Often, LoVerme said, women request repeat surgeries to enlarge the breasts a second time. Other possible problems, he said, are wrinkling or rippling in the implant, infection , bleeding, or that the breasts simply won't feel natural. One particularly dreaded complication is called "capsular contracture": The breast reacts to the foreign body within it with a buildup of scar tissue that hardens and sometimes even squeezes the implant, making it rock-like and painful. If the contracture gets bad enough, the implant must be removed. For the earlier generation of silicone implants, he said, as many as 20 to 25 percent of women suffered capsular contracture. With the new generation, it is about 8 percent among first-time breast-enlargement patients.

Most implants eventually rupture or wear out. The FDA suggests that women have an MRI every three years to make sure their silicone implants are intact. Women with saline know immediately whether one has ruptured because the breast flattens. They need not fear health risks from the saline because the body is made up largely of salt water.

Given the more natural feel of silicone, it is not surprising that many women are choosing it, "but it is worrisome," said Amy Allina , program director of the National Women's Health Network, which opposed the FDA approval. "It's worrisome because the FDA is telling women these products are safe even though they don't really know that."

Implant manufacturers are now required to perform 10-year follow-up studies on women who get implants, but that should have been done before approval, she said.

Women "should know that we are particularly concerned about what happens when they break. And know that they will break," Allina said.

Martha Gallant , a retired high school biology teacher, had a saline implant on her left side for five years, replacing a breast sacrificed to cancer. It healed but never felt natural, and at times she could even hear it slosh. It was hard for her to sleep on her left side because of how the water shifted.

Eventually it developed some capsular contracture and other problems, and she knew it needed to be replaced.

Gallant, of North Kingstown, R.I., has fibromyalgia -- a chronic pain syndrome that was one of the diseases suspected of a link with silicone leaks. But she opted for a new silicone implant last year as soon as Breuing, her reconstructive surgeon, described the new gel models. As a patient who needs breast reconstruction rather than simply enlargement, she was eligible for silicone even before the FDA approval.

Now, she said, "I feel just like I have two normal breasts, while I did not feel that way with the saline." She is so happy with the silicone, she said, that she even has friends -- only close friends -- prod it, and they tend to say, "Oh my God, it feels just like the other side!"

Surgeons say that the silicone is also a particular boon for women who have very little breast tissue or are very thin. The saline implants tended to be much more obvious in them.

The buzz about silicone has some women talking about an "upgrade" from saline to silicone, surgeons say, though doctors tend to discourage replacement if there is nothing actually wrong with the existing implant.

If there is a factor that may slow the rush to silicone, it is price, said Dr. LoVerme of Newton Wellesley, whose consultations with implant patients used to take an hour and now run closer to 90 minutes to discuss the relative benefits of saline and silicone.

Among his implant patients, he said, about half are opting for silicone these days, and those who choose saline tend to do it for financial reasons: A pair of saline implants costs about $1,000, compared with about $2,000 for silicone. Total costs for the operation tend to run between $6,000 and $9,000 he said, and insurance tends to cover only reconstruction.

But money is not the paramount consideration, LoVerme said. Results are.

Five years ago, he said, if someone he was close to had wanted implants, "I would have recommended saline. But with these new silicone implants, personally, I think for many people they're just better than saline."

Carey Goldberg can be reached at