Saline vs. Silicone Breast Implants

Reviewed by Walter Erhardt, MD 

Considering breast augmentation surgery with implants? There are currently two main options — saline (salt water) breast implants and silicone breast implants. In determining which type is the better option for you, it’s important to weight their pros and cons. There is no right or wrong answer.

Saline Breast Implants

Understanding the anatomy of a saline breast implant may help you make your decision. Breast implants can be filled with saline or silicone gel; however, the casing or outer shell for both is composed of silicone.

Saline breast implants come in different sizes, shapes and profiles. The surface of the outer shell is another component of breast implants. It can be either smooth or textured.

Common saline implant types include:

• Single lumen, prefilled to a fixed volume, with no valves for filling during surgery or for adjusting after surgery.
• Single lumen, filled with a fixed volume of saline during surgery through a valve, with no adjustments to the implant volume.
• Single lumen, filled during surgery, with a valve for the purpose of adjusting the volume of saline following surgery.

Saline-filled breast implants can be placed in any of the various implant placement positions. These positions include subglandular (over the muscle), partial submuscular (the top two-thirds is covered by the muscle) and complete submuscular (under the muscle). Another part of the equation is incision type and location. There are several options, including inframammary (crease where the breast and chest come together), periareolar (nipple), transaxillary (armpit) or TUBA (belly button).

Placement of saline breast implants tends to involve shorter incisions than those used with silicone implants. This is because saline implants are filled after placement, whereas silicone implants are pre-filled. For the same reason, saline implants often can be adjusted after surgery; the doctor can use a syringe to put in more liquid or take some out. In contrast, the size of standard pre-filled silicone implants is permanent.

Rupture Risks

The main advantage of the saline-filled breast implant is that if it ruptures, the saline (saltwater solution) is harmlessly and seamlessly absorbed by the body. Another rupture-related advantage of saline breast implants is that it is obvious if a saline implant ruptures because it deflates immediately. This is not true with silicone gel-filled implants. The silicone gel leaks out slowly, which is why the Food and Drug Administration (FDA) recommends that women with silicone gel-filled implants undergo magnetic resonance imaging (MRI) to check for ruptures three years postoperatively, and then every two years after that. Both implant types should be removed if they rupture.

The controversy surrounding silicone gel-filled implants centered largely around what happens to the gel filling if the implant shell ruptures. A group of women alleged that this errant gel caused autoimmune and connective tissue diseases. The FDA removed silicone-filled breast implants from the market in 1992 as a result of these claims. After a thorough investigation, the FDA could find no connection between silicone breast implants and connective tissue or autoimmune disease. As a result, the agency re-approved silicone gel-filled implants in 2006. Now, silicone breast implants are approved for women of all ages who need breast reconstruction and for women aged 22 and older seeking breast augmentation.

The Touch, The Feel

The main disadvantage of saline-filled implants is their feel. Many women prefer the more natural-feeling silicone gel to the water balloon-like feel of saline-filled implants. That said, newer surgical techniques, such as placing the saline implant behind the chest muscle and slightly overfilling it, may make the implant feel more like real breast tissue.

The Ripple Factor

Saline implants also are more likely to show rippling or wrinkling than silicone gel-filled implants. Rippling occurs when the saline fill and the elastic silicone polymer shell interact. This effect may be more pronounced in women with thin skin and very little breast tissue because the small ripples in the implant may be more visible through their crepe-like skin.

Cost of Saline Implants

Breast augmentation with saline implants costs approximately $1,000 less than with silicone gel-filled implants. There are many reasons for the difference in price, including the cost of the implant-filling material.

Silicone Breast Implants

In general, silicone gel-filled implants are smoother and softer than their saline-filled counterparts. Silicone implants feel like a semisolid gel, while saline implants are often likened to water balloons. Many women prefer the softer, more natural feel of silicone implants to saline breast implants. This is especially true of women with little breast tissue, including those undergoing breast reconstruction following breast cancer. Silicone-gel implants are also less likely to ripple than saline breast implants.

There are several types of silicone-filled breast implants:

• Single lumen, prefilled by the manufacturer to a specific volume.
• Double lumen, with the inner lumen prefilled by the manufacturer to a specific volume and the outer lumen filled during the breast augmentation procedure with a fixed volume of silicone gel using a valve in the implant.
• Double lumen, with the outer lumen prefilled by the manufacturer with a fixed volume of silicone gel and the inner lumen filled during the procedure through a valve in the implant. This third type allows for adjustments to the filler volume after surgery.
• Highly cohesive silicone gel implants, which contain a gel that is more viscous than the gel used in the other implants — similar to the consistency of a gummy bear candy. If these gummy bear breast implants rupture, the gel will not migrate due to its consistency. These implants are not yet approved by the FDA.

A Brief History

The Food and Drug Administration (FDA) removed silicone-filled breast implants from the market in 1992 after lawsuits alleged these implants increased a woman’s risk of autoimmune and connective tissue diseases. This legislative move left only saline-filled implants available in the United States.

From 1992 to 2005, the only surgeons allowed to use silicone breast implants were those involved in clinical studies evaluating the use of silicone implants for breast reconstruction and revision breast augmentation. After a thorough investigation, the FDA could not find any link between silicone breast implants and connective tissue or autoimmune disease. As a result, they re-approved silicone-gel filled implants in 2006. Now, silicone breast implants are approved for women of all ages who need breast reconstruction and for women age 22 and older for breast augmentation.

In 2011, five years after the re-approval of silicone breast implants, the FDA stated that these breast implants remain relatively safe, but are not meant to be permanent fixtures. The agency plans to continue tracking safety information on silicone breast implants.

Cost of Silicone Implants

Breast augmentation with silicone gel-filled breast implants costs about $1,000 more than breast augmentation with saline-filled implants. There are many reasons for the discrepancy, including the cost of the implant-filling material.

Weighing the Pros and Cons

Both saline and silicone breast implant fillers have pros and cons that must be weighed when making your decision.

An advantage of saline breast implants is that, if the shell ruptures, the saline (salt solution) is absorbed by the body. In contrast, silicone gel may stay inside the implant shell or leak outside of the shell if it ruptures. If a saline breast implant ruptures, it is noticeable because the implant deflates. This is not necessarily the case with silicone breast implants. Sometimes there are no obvious symptoms when a silicone-gel implant ruptures. This problem, referred to as “silent rupture,” was one of the concerns expressed by the FDA.

As a result, the FDA recommends that women with silicone-gel filled implants undergo magnetic resonance imaging (MRI) three years postoperatively, then every two years to check for ruptures. Silicone implants must be removed if they rupture.

Other differences involve how the breast implants are filled. Saline implants are filled after they’re implanted, which means that they require a smaller incision than prefilled silicone breast implants. Also, many saline implants can be adjusted after surgery. The doctor can use a syringe to add or remove liquid. The size of standard prefilled silicone implants cannot be changed.

Implant Placement

Today’s silicone gel-filled implants can be placed in any of the various implant placement positions, including:

• subglandular (over the muscle)
• partial submuscular (the top 2/3 is covered by the muscle)
• complete submuscular (under the muscle)

Saline implants, due to their greater tendency for rippling and wrinkling, most frequently are placed in the submuscular position.

Discuss the Benefits and Risks of Silicone Implants with a Surgeon

When deciding which type of implant is best for you, discuss your options with a board-certified plastic surgeon. Because of the former FDA restrictions on silicone implants, which were in place for more than 14 years, many surgeons have little or no experience with silicone implants. You should consult a plastic surgeon who has extensive breast implant experience with the various types of breast implants.

Experienced breast augmentation surgeons can explain the benefits and risks for certain implant types depending on your personal anatomy, implant placement, and type of implant incision.