Smooth implants placed subglandularly produce the best cosmetic result

James L. Baker, Jr., MD Winter Park, FL

I have used only smooth implants since January 1992, and I place them on top of the muscle. I believe significant cosmetic benefits are achieved with this approach.

I always discuss the various options for implant type and placement with my patients. I tell patients that if they want textured implants, these should be placed subpectorally because wrinkling can be expected. Wrinkling may occur on the lateral and inferior poles and medially in the upper cleavage area. So I believe that textured implants must be placed completely submuscularly to avoid these problems, and, in my opinion, this produces a less satisfactory cosmetic result. I do show patients a photograph of a good result with an implant placed subpectorally, and I explain that it has more fullness in the upper pole, as well as lateralization and movement when the pectoral muscles are tightened. This is a consideration because many of these patients “work out” regularly. I rarely encounter a patient who insists on subpectoral placement.

In addition to the undesirable rippling effect, I have encountered a high number of seromas using textured implants. This is an important factor in my preference for smooth implants.

Advocates of textured implants point out the advantage of a reduced incidence of capsular contracture. Although the contracture rates with textured implants are reportedly lower than those with smooth implants, in my experience the difference has not been dramatic. When I was using textured implants, both gel and saline, the incidence of contracture was about 18%. Using smooth saline implants, we obtained about a 20% contracture rate, and smooth gel implants yielded about 30% contracture.

If contracture does occur, I find that textured implants do not lend themselves to a closed capsulotomy. In my opinion, the only treatments for contracture with textured implants are papaverine HCL (Pavabid^®) or reoperation. Papaverine is effective about 55% to 60% of the time in relaxing the capsule to some degree. The dosage is 150 mg b.i.d. for several months. However, long-standing contractures, when treatment is started late, are resistant to this drug. This is because papaverine acts on the myofibroblast cells, which diminish as the capsular collagen stabilizes.

I have no problem with using smooth saline implants. In fact, the more I work with them, the more I like them, particularly in patients with average body fat. Saline implants have two important advantages over silicone gel devices. First, they are livelier implants. They produce a fluid wave that makes the breasts bouncier, which is very natural looking. Second, they stay warm. When women with silicone gel implants, especially those who have a small amount of breast tissue, emerge from a cold swimming pool, the gel may remain cold for about 45 minutes to an hour. Saline implants, on the other hand, maintain their core temperature very well. My patients have been very happy with these implants.