Pr040001542p

Cosmetic Special Topic Textured-Surface Saline-Filled Silicone BreastImplants for Augmentation Mammaplasty Scott L. Spear, M.D., Mohamed Elmaraghy, M.D., and Christopher Hess, M.D.
Washington, D.C. The earliest silicone breast implants were smooth-sur- sues include but are not necessarily limited to face, silicone rubber devices filled with either silicone gel toxicity, immunogenicity, teratogenicity, carci- or saline. Because of persistent problems with capsular nogenicity, and potential interference with contracture, polyurethane-covered silicone implants weredeveloped as an alternative. Particularly in the short run, mammography. Efficacy issues include but are these alternatives proved highly successful at reducing the not necessarily limited to risks of capsular con- incidence of capsular contracture. By 1990, polyurethane- tracture, deflation, palpability, and rippling.
covered implants were rapidly becoming the preferred The distinction between textured and smooth implant choice of many plastic surgeons, but for legal, saline devices is largely one of efficacy, al- regulatory, financial, and safety reasons they were with-drawn from the market by Bristol-Myers in 1991. Mean- though there is some evidence that there may while, during the late 1980s, surface texturing and im- be more particulate silicone shed from the proved materials became available on other silicone breast surface of textured implants than smooth implants and expanders. Most studies suggest that tex- ones.39 The medical significance of such shed- tured-surface silicone gel–filled implants, saline-filled im- ding is unclear.
plants, and tissue expanders have less frequent capsularcontracture than their smooth-surface counterparts.
The early history of silicone breast implants (Plast. Reconstr. Surg. 105: 1542, 2000.) involved the use of saline-filled or silicone gel–filled devices with smooth silicone surfaces. Al-though both of those implant types were sub- Textured-surface, saline-filled silicone im- stantial improvements over earlier options plants are one of several options available to- such as Ivalon sponges, they too ultimately suf- day for breast augmentation. Understanding fered from a significant risk of capsular con- their appropriate use requires a review of the tracture.1–4,13–16 For reasons of efficacy, silicone history of breast implant development, includ- gel implants were more popular than saline- ing the development of textured surfaces.1–40 filled implants from the beginning. Thus, The literature on this subject can be confusing; much of the early literature and clinical energy thus, it is important to make certain distinc- surrounding silicone implants dealt with sili- tions clear from the outset. Tissue expanders cone gel implants and potential for their cap- are different devices than implants and behave sular contracture, including its cause and differently than implants. Data relevant to tis- avoidance. Factors implicated in the develop- sue expanders are not necessarily true for im- ment of capsular contracture included surgical plants and vice versa.18 Similarly, silicone gel– technique, bleeding, subclinical infection, pa- filled breast implants are different devices than tient sensitivity, soft-tissue environment, and saline-filled implants.3,4 The evidence regard- even silicone itself. Some of the most common ing textured, silicone gel–filled implants is not strategies used in an attempt to defeat capsular necessarily relevant to saline-filled devices. Fi- contracture included systemic antibiotics, local nally, for reasons that are not well understood, antibiotics, steroid solution irrigations, intralu- animal research of breast implants has been a minal steroids, submuscular placement, low- poor predictor of clinical outcomes.12,18,26 bleed silicone elastomer shells, underfilled im- The evaluation of breast implants necessarily plants, double-lumen implants, and saline- covers two areas: safety and efficacy. Safety is- filled implants.
From the Division of Plastic Surgery, Georgetown University Medical Center. Received for publication February 25, 1999; revised May 18, 1999.

Vol. 105, No. 4 / AUGMENTATION MAMMAPLASTY The nearly universal experience by plastic about the fate and toxicity of the polyurethane, surgeons that early-generation, smooth, sili- the evidence is substantial that these implants cone gel–filled breast implants placed in the were impressively resistant to capsular contrac- subglandular plane had a significant risk ture, particularly for the first decade or so after of developing capsular contracture led, in part, their implantation.9–11,16,40 The increasing pop- to the development of the polyurethane- ularity of polyurethane-covered implants covered silicone gel–filled breast implant through the 1980s coupled with their favorable (Fig. 1).1,5–7,9–11 Although there were more than record of infrequent capsular contracture nat- one type and manufacturer of polyurethane- urally led to a search for other options in tex- covered implants and although they have al- tured surfaces that would avoid the long-term ways been associated with nagging questions doubts about polyurethane. In particular,there was the need of avoiding the possiblebreakdown products of polyurethane andavoiding the separation or delamination of thetextured surface from the implant. This wastrue because the generally favorable reportsregarding the use of polyurethane were tem-pered by some reports of late capsular contrac-ture after the textured surface had delami-nated from the implant, thus, effectivelyconverting it to a smooth-surface device.
During the same time period of the 1970s and 1980s, other steps had also proven some-what effective in dealing with the frequency ofcapsular contracture, particularly the use oflow-bleed elastomer shells and saline-fill solu-tions, both of which effectively reduced theamount of silicone gel to which the tissues wereexposed.3,4,13,21,22,24,28,36 Thus, textured-surface, silicone implants were developed in the late 1980s as an obviousalternative to the attached textured surface ofpolyurethane. Because of earlier work to im-prove the performance and decrease the sili-cone permeability of the elastomer shells, thetextured-surface, silicone elastomer shells weredeveloped at a time when all silicone breastimplants were becoming available as strongerand less permeable versions of earlier materi-als. Four different types of textured surfaceswere available more or less simultaneously:polyurethane, Biocell, MSI, and Siltex.
Dow Corning developed and manufactured the MSI surface, which is an extremely regularsurface of projecting, minute silicone rubberpapillae created with laser technology (Fig. 2).
Mentor Corporation developed the Siltex sur-face, which is a patterned surface created as anegative contact imprint off of a texturingfoam (Fig. 3). The McGhan Medical Corpora-tion developed the Biocell surface, which is anaggressive open-pore textured surface createdwith a lost-salt technique and that seems, at FIG. 1. (Above) Polyurethane-covered silicone gel-filled breast implant. (Below) The appearance of the polyurethane least in many ways, similar to polyurethane as seen by electron microscopy.

PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 2. (Left) The MSI textured surface. (Right) A close-up view of its surface as seen by The various textured surfaces became avail- urethane-covered implant from the U.S. mar- able at approximately the same time and could ket in 1991 by Bristol Myers, the demand for be found on silicone gel–filled implants, saline- other textured-surface breast implants was im- filled implants, and tissue expanders. Because mediate. As a result of the FDA hearings of much of this innovation occurred just before 1991 and 1992 and the contemporaneously ex- and during the FDA hearings on silicone im- tremely hostile litigation environment, Dow plants, there has been only a modest amount of Corning ceased its breast implant business and information available regarding how, and how the MSI surface was simultaneously withdrawn, well, these textured surfaces work. However, despite early, quite favorable anecdotal experi- certain things did become clear. First, each of ence with it.
the available textured surfaces was manufac- In the United States, by early 1992, two types tured differently, looked different, and be- of textured surfaces were available on tissue haved differently in the clinical environment.
expanders and saline-filled implants: the Bio- Second, textured surfaces behaved differently, cell surface and the Siltex surface. Mentor at depending on whether they were used on sili- that time was the only manufacturer approved cone gel implants, saline implants, or expand- to market textured-surface, silicone gel–filled ers. The evidence is convincing that neither implants in an FDA-approved "adjunct study." the MSI nor the Siltex textured expanders or More recently, McGhan has won approval by implants induced the type of tissue ingrowth as the FDA for its own adjunct study, which in- seen with polyurethane. The Biocell expand- cludes its Biocell textured-surface, silicone gel– ers, on the other hand, usually incited tissue filled implants. For practical purposes, we have ingrowth, whereas the Biocell implants did so had nearly 10 years of clinical experience with only occasionally.41 Whereas the MSI and Siltex two types of textured-surface breast implants.
surfaces were resistant to tissue ingrowth, the Many surgeons have had their own individual Biocell surface promoted ingrowth, particu- experiences with these various devices, and we larly when native tissues were placed in inti- now have a handful of reasonable studies on mate contact with the Biocell surface such as which to make some judgment.
was seen with tissue expansion or a tight pocket The stage was initially set in 1981 with re- around an implant.
ports first by Capozzi and Pennisi, and eventu- With the voluntary withdrawal of the poly- ally by many others, that polyurethane-covered,

Vol. 105, No. 4 / AUGMENTATION MAMMAPLASTY ture rate around those early-design smooth,silicone gel–filled implants and a 20 percentrate around smooth, saline-filled implants.
Some of these patients were radiated, whichhelps explain the high frequency of capsularcontracture in both groups. On a follow-up ofthis same study published 6 years later in 1990,the incidence of capsular contracture at 6 yearsremained stable and was 50 percent in thesilicone gel group and 16 percent in the saline-filled group. The report by Lavine in 1993reviewed 1091 women who had undergonemostly subpectoral breast augmentation by us-ing smooth, saline-filled implants over a 10-year period with an overall capsular contrac-ture rate of 6.1 percent. Thus, even without thebenefit of textured surfacing in these studies,saline-filled implants placed subpectorally hadfairly well proven to have a lower incidence ofcapsular contracture than the early versions ofsmooth-surface, silicone gel–filled implants.
The problems with saline-filled devices, on theother hand, have had more to do with defla-tion, visibility, and palpability.
Much of the impetus for developing a tex- tured surface, thus, was focused primarily onthe silicone gel–filled implant, for which therewas more of a history of a problem with capsu-lar contracture. Publications by Hakelius andOhlse´n in 1992 and Pollock in 1993 gave earlysupport to a lower capsular contracture ratewith textured-surface, gel implants.19,20 Hake-lius and Ohlse´n performed a 1-year, randomlyassigned, double-blinded study of subglandularbreast augmentations in 25 women by using amore modern design McGhan smooth, siliconegel implant on one side and a McGhan, Bio-cell, textured silicone gel implant on the otherside. The textured silicone gel device per-formed dramatically better, and 12 of the 25women ultimately asked to replace the smoothimplant on one side. Forty-four percent of the FIG. 3. (Above) The Siltex textured-surface, saline-filled breast implant. (Below) A close-up of its surface as seen by smooth, silicone gel–filled implants had capsu- lar contracture, whereas none of the texturedimplants did.
silicone gel–filled implants produced a dra- In the publication by Harlan-Pollock in 1993 matic lowering of the capsular contracture rate reviewing 197 subglandular breast augmenta- compared with the smooth silicone gel–filled tions (98 Mentor, smooth, double-lumen sili- implants available at that time.1,5–7,9–11 During cone gel and 99 Mentor, Siltex surface, silicone the same time period, several studies demon- gel), the smooth implants had a 21 percent strated that saline-filled implants had a signifi- incidence of capsular contracture, whereas the cantly lower rate of capsular contracture than textured-surface implants had a 4 percent inci- silicone gel–filled devices.3,4,13,21 Asplund, in a dence. Coleman's two reviews of his experi- 1984 report on submuscular breast reconstruc- ence, the first at 1 year and the other after 3 tion, described a 54 percent capsular contrac- years, confirmed that after subglandular breast

PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 augmentation, the Mentor Siltex textured sur-face was dramatically effective in reducing cap-sular contracture to 11 percent of patientscompared with 59 percent for smooth Mentorgel-filled implants.
Multicenter data presented on behalf of both Mentor and McGhan Corporations wouldseem to be in general agreement with theabove studies. The Mentor multicenter "ad-junct" study, composed of more than 1500 in-vestigators and more than 15,000 Siltex tex-tured-surface, silicone gel–filled implants in avariety of clinical situations, has produced acapsular contracture incidence per breast ofroughly 5 percent. The McGhan prospectiveclinical study of silicone gel–filled implantsyielded a similar 5.5 percent textured-surface,implant capsular contracture incidence per im-plant at 4 years. During the same time period,smooth-surface, McGhan gel implants used inbreast augmentation had a 10.6 percent inci-dence per implant of capsular contracture.42 Inboth the McGhan and Mentor studies, the datafor subglandular and submuscular implantshave so far been lumped together, so that noconclusion can be drawn yet from those studieson subpectoral positioning. The above data forMcGhan was reported per implant, and in thecase of breast augmentation, with mostly uni-lateral capsular contracture, the per-patient in-cidence of contracture was 15.8 percent forsmooth gel implants and 9.2 percent for tex-tured gel implants.
The data we have reviewed strongly support certain conclusions. Polyurethane-covered im-plants were effective at reducing capsular con-tracture compared with a wide variety of earlyversions of smooth, silicone gel–filled devicesavailable in the 1970s and early 1980s. Saline-filled, smooth implants were also somewhateffective at reducing the incidence of capsularcontracture compared with smooth, gel-filleddevices, particularly when placed subpec-torally. And, both the McGhan Biocell texturedsurface and the Mentor Siltex textured surfaceare generally effective in reducing the inci-dence of capsular contracture. Interestingly, todate, there have been no published reportsdirectly comparing the efficacy of the mildlyaggressive Siltex textured surface with themore aggressively textured McGhan Biocellsurface. Several studies have looked at the ben- FIG. 4. (Above) The Biocell textured-surface, tissue ex- efits of submuscular or subpectoral positioning pander. (Center) The Biocell textured-surface, saline-filledbreast implant. (Below) A close-up of the implant's textured over subglandular placement, with the evi- surface as seen by electron microscopy.
dence supporting a reduction in capsular con- Vol. 105, No. 4 / AUGMENTATION MAMMAPLASTY tracture with implants under some muscle par- surgeons could distinguish clinically between the smooth and textured implants.
Information on the combined benefits of sub- Tarpila et al. from Sweden performed a sim- muscular positioning and surface texturing ilar study in subglandular augmentation in 21 awaits further studies and their publication.
women by using McGhan Biocell and smooth, The initial work on textured surfaces and saline-filled implants randomly on opposite saline-filled devices was in expanders. Max- sides.35 The implants were overfilled 10 cc, and well's landmark study on breast reconstruction antibiotics or antibacterials were not used lo- with Biocell textured surface, integrated-valve, cally or systemically. At 1 year, 29 percent of anatomic tissue expanders dramatically dem- textured and 38 percent of smooth implants onstrated the effectiveness of these devices not exhibited Baker III capsular contractures, a only in avoiding capsular contracture but in difference that did not reach statistical signifi- achieving a satisfactory breast shape.43 How- ever, there was contradictory information in Of special interest is the McGhan multi- both animal models and clinical experience, center study combining subglandular and sub- with some authors finding no advantage in pectoral breast augmentation. At 4 years, the reducing capsular contracture by using tex- capsular contracture incidence per patient for tured surfacing in inflatable devices. Neverthe- smooth saline-filled implants was 7.4 percent, less, at least in breast reconstruction, textured- and 8 percent for textured-surface, saline-filled surface, integrated valve, inflatable tissue implants; no significant difference. The inci- expanders have been accepted by many as pref- dence of capsular contracture per breast would erable to smooth devices.42,44 have been roughly half of that, i.e., 3.7 percent Against this background of information first and 4 percent, respectively.
on textured surfaces and then on saline-filled Both Truppmann and Mladick have sepa- devices, we have additional information specif- rately reported an incidence of capsular con- ically on textured-surface, saline-filled im- tracture near 1 percent in subpectoral aug- plants. However, before looking at these data, it is critical to remember that even smooth- implants.22,28,42 On the basis of these studies surface, saline-filled implants placed subpec- and earlier studies on breast reconstruction torally have a favorable record in terms of cap- with saline-filled implants, it seems clear, par- sular contracture.21,22,28 Also, there are two ticularly for saline-filled devices, that subpec- benefits of subpectoral positioning with saline- toral positioning is very protective against cap- filled implant: decreased capsular contracture sular contracture. With an incidence of near 1 and decreased implant visibility and palpabil- percent as reported by Mladick22 and others ity. In 1994, Burkhardt and Demas reported around smooth, saline-filled implants for their experience with Mentor's Siltex textured, breast augmentation placed subpectorally, it is saline-filled implant used randomly on one not clear that surface texturing has much ad- side of subglandular breast augmentation.23 ditional to offer in avoiding capsular contrac- The Siltex side had a 2 percent incidence of ture when submuscular placement is being capsular contracture compared with 40 per- considered. Thus, although the benefit of sub- cent on the opposite side with a smooth im- muscular positioning of saline-filled implants plant. Of interest in this study is the preference in avoiding capsular contracture seems un- of some of the patients for their firmer smooth equivocal, the information on surface textur- inflatable implant over the opposite side's ing for saline devices is more complicated.
softer textured implant, because the smooth The published data we have reviewed from device was less palpable or visible. In 1995, several different studies suggest then that sub- Burkhardt and Eades reported on a similar glandular breast augmentation with smooth, study comparing McGhan's Biocell textured- saline-filled implants may yield a capsular con- surface, saline-filled implant to its smooth tracture incidence per implant of between 23 counterpart again in subglandular breast aug- and 40 percent. Surface texturing has the po- mentation.29 Thirteen percent of textured de- tential to reduce that incidence to somewhere vices exhibited Baker class III or IV capsular between 2 and 29 percent. However, the Siltex contracture compared with 23 percent of textured saline-filled implant may have the dis- smooth devices. Unlike the Mentor textured- advantage of being more palpable and visible surface implants, neither the patients or the than its smooth counterpart, to some extent

PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 possibly negating its advantage of less capsular plants in subpectoral breast augmentation. In contracture in the subglandular position. The most patients, they did fine in terms of capsular McGhan Biocell textured surface also seems contracture (Fig. 5). Although we initially used effective at reducing the incidence of subglan- them with a dilute intraluminal solution of dular capsular contracture, but the McGhan Solu-medrol, we stopped that practice because Biocell saline-filled implant also may be more of the evidence and our own experience that visible and palpable, than a smooth implant.
submuscular saline-filled implants do not need Although there is no evidence that the Mentor the help of steroids. Our experience with sub- Siltex textured, saline-filled implants experi- glandular, saline-filled implants has not been ence tissue ingrowth, the McGhan Biocell sa- quite as favorable. Both in primary and second- line implant will achieve ingrowth in some pa- ary cases of subglandular breast augmentation, tients. The tighter the pocket and the more some smooth and some textured saline-filled pressure exerted by the implant against sur- implants have been more palpable and more rounding native tissues, the more likely in- visible than subpectoral implants. And, it is our growth will occur. However, it is not clear that impression that there have been more capsular tissue ingrowth around implants is necessarily contractures, although we have not studied desirable, although many if not most surgeons these patients carefully enough yet to quanti- prefer tissue ingrowth around expanders.
tate the difference. And when the implants are Of course, there is more to breast surgery placed subpectorally, there is the important than just capsular contracture. What about added advantage of improved mammography.
shape, appearance, feel, and mammography? Based on the published studies and our own My personal experience with saline-filled im- clinical experience, we make these recommen- plants began in the late 1980s when I substi- dations. For reasons of softness, shape, feel, tuted smooth saline implants occasionally for appearance, and mammography, saline-filled smooth double-lumen silicone gel–filled im- implants do best when placed beneath all or FIG. 5. A patient before (above) and after (below) subpectoral augmentation mammaplasty using 360-cc round, smooth-surface, saline-filled breast implants. A patient with healthy andsufficient soft-tissue coverage such as this would also be an appropriate candidate for a sub-glandular breast implant for which surface texturing would provide added protection againstcapsular contracture without undue risk of undesirable palpability or visibility. The subpectoralapproach is still preferable in terms of mammography.
Vol. 105, No. 4 / AUGMENTATION MAMMAPLASTY some portion of the pectoralis major muscle.
contracture, mammography, and implant pal- In very thin and small-breasted women without pability, this is better done subpectorally; it can ptosis, even more or total muscle cover is an also be done in the subglandular space in pa- option. This finding is particularly true for sa- tients with adequate soft tissue. Because of the line-filled implants, even more so than for gel- very low risk of capsular contracture around filled implants because of possible palpability, subpectoral, smooth-surface, round saline- visibility, and rippling problems from saline.
filled implants, there would seem to be little On the other hand, subglandular placement is advantage in the use of round, textured- a more reasonable option in patients with surface, saline-filled implants in the subpec- some breast tissue and subcutaneous fat, and a toral position, except for reasons of personal healthy, reasonably thick, elastic youthful skin preference or perhaps in a patient who has a envelope. The healthier the soft-tissue cover, poor record with capsular contracture associ- the better subglandular saline-filled implants ated with an earlier smooth round device.
perform and feel. Published reviews support Technically, breast augmentation with the proposition that textured-surface implants smooth, round saline-filled implants resembles offer some special advantage in these patients historical techniques with silicone gel implants, for reducing capsular contracture when the for which implant mobility and large pocket implant is placed subglandularly (Table I).
dissection were desirable. With this large- The ptotic patient with stretched out and thin pocket approach by using saline-filled im- skin is problematic. Although subpectoral po- plants, particularly larger ones, there may be a sitioning risks creating a double-bubble with tendency for increased soft-tissue stretching the breast hanging below the implant, subglan- and thinning as a possible result of the repeti- dular positioning with a textured saline-filled tive water-hammer effect of the salt water. Al- implant placed just beneath thinned-out breast though also possible with silicone gel–filled skin runs the risk of visible rippling and an implants, particularly textured ones, this effect implant that is too easily palpated. The same was not commonly seen with them. Such soft- may be true for the patient who has had pre- tissue stretching would likely increase the risk vious breast implants, for whom those implants of rippling, palpability, and ptosis.
may have thinned or stretched out the soft The textured-surface, saline-filled implants tissues (Table II). In these difficult situations, are designed to retain softness without the repair of the soft tissues by using mastopexy or need for the mobility seen with smooth ones.
flap techniques may be necessary to use a sa- In breast augmentation with the McGhan Bio- cell textured-surface implant, where tissue in- However, surface texturing may also play a growth or some adherence is a real possibility, role when trying to control breast shape (Fig.
precise pocket dissection and conservative im- 6). The various designs of anatomic, saline- plant volumes (volumes of 380 cc or less) can filled implants come with textured surfaces.
yield breasts with minimal implant mobility, Although not proven, it is believed by some palpability, rippling or ptosis, yet with reason- that these textured surfaces along with careful able softness and an attractive, more natural surgical dissection and appropriate postopera- shape. However, the drawback of this approach tive care may help to reduce implant rotation is a certain lack of mobility, a solution that and mobility so as to create and best control some surgeons and patients do not accept. The breast shape. Although for reasons of capsular Mentor Siltex surface, although effective at re- Capsular Contracture around Silicone Gel-Filled Implants Cap. Contr. around Cap. Contr. around around Subgland.
around Subgland.
Textured Gel (site not specific) (%) not specific) (%) Mentor Adj. Clin.
McGhan Core Clin.
Cap. Contr., capsular contracture; Subgland., subglandular; n/a, not applicable; Adj. Clin., adjunct clinical trial; Core Clin., core clinical trial.

PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 Capsular Contracture around Saline-Filled Implants Cap. Contr. around Cap. Contr. around Textured Gel (site not McGhan Core Clinical Study Cap. Contr., capsular contracture.
FIG. 6. A patient (above) before and (below) after subpectoral augmentation mammaplasty using 300-cc anatomic, textured-surface, saline-filled breast implants. A patient with this muchsoft tissue might also be a reasonable candidate for a subglandular, textured, anatomic implantwith precise pocket dissection.
ducing capsular contracture, does so without has been the historical bug-bear associated tissue ingrowth or adherence. Clinically, the with the efficacy of silicone gel–filled breast technique and results with the Mentor Siltex implants, palpability, visibility, and rippling as surface more closely resemble those with un- well as capsular contracture have been the encapsulated smooth implants for which mo- problems with saline-filled ones. Surface tex- bility rather than adherence is the rule. When turing has, thus, played a more important role the Biocell surface is used in secondary cases or in silicone gel–filled implants than in saline- after large pocket dissections, tissue ingrowth filled ones. Textured, saline-filled breast im- and adherence are also less likely, and in those plants make the most sense in two scenarios: circumstances too, mobility rather adherence first, with anatomic designs where the goal is to is the rule. For that reason, anatomically better control and create a certain breast shaped textured implants are best used only shape; and second, in patients with adequate when there is some control over the pocket soft tissue for whom subglandular positioning size, shape, and fit to the implant; otherwise, is desired for whatever reason. For routine sub- the implant will lose its proper orientation.
pectoral breast augmentation, there are not, at In conclusion, whereas capsular contracture the present time any clear documented advan- Vol. 105, No. 4 / AUGMENTATION MAMMAPLASTY tages or for that matter disadvantages to round 14. Ersek, R. A.
Rate and incidence of capsular contracture: textured, saline-filled implants. Subpectoral A comparison of smooth and textured silicone double-lumen breast prostheses. Plast. Reconstr. Surg. 87: 879, positioning of saline-filled implants alone seems very effective at reducing the incidence 15. Coleman, D. J., Foo, I. T. H., and Sharpe, D. T.
of capsular contracture without the added risk tured or smooth implants for breast augmentation? A of increased palpability and implant visibility, prospective controlled trial. Br. J. Plast. Surg. 44: 444, which may occur in subglandular positioning 16. Handel, N., Silverstein, M. J., Jensen, A., et al.
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