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The below extracts, written by Dr Farhadieh, are from the Breast Augmentation chapter of the international reference Plastic Surgery textbook; Plastic Reconstructive Surgery. Dr Farhadieh is also the textbook's current chief editor. 


Silicone breast implants can be divided into five generations based on shell thickness, texture and implant fill. Current implants are divided by gel fill into saline or silicone. The silicone fill is further subdivided into stable and soft, based on level of molecular cross linkage. By shell, they are divided into textured and smooth, all made of silicone polymers and finally, by shape into round and anatomical.

First generation implants manufactured by Dow Corning in 1962 were composed of viscous silicone gel containing a thick tear drop shell. In the 1970s, high capsular contracture rates led to an evolutionary step towards a second generation of softer implants, these were smooth round, seamless and contained less viscous silicone. Although reducing capsular contracture rates, they were associated with ‘gel bleeds’, which has also been implicated in capsular contractures. This led to a third generation implants which had a strengthened silicone shell. The fourth generation of textured implants were made in part to emulate polyurethane foam’s natural pores. They were however, withdrawn in 1990 after animal studies showed their carcinogenic nature.


Biocell developed by McGhan Medical (owned by Allergan) was withdrawn from the European markets in December 2018. Biocell is composed of an irregular open pore textured surface. These pores are developed through an adhesive effect. This shell characteristic has been used for both saline as well as silicone filled implants resulting in immobile yet soft implant feel and lower contracture rates.

Siltex developed by Mentor (owned by Johnston & Johnston) has a textured surface that do not adhere to the surrounding tissues, meaning they are mobile in the pocket resulting in lower contracture rates (saline or silicone filled).

Fifth generation of silicone implants are textured with form stable silicone achieved by increasing the cross linkage of the silicone gel which assists maintaining their shape.


There are inherent risks involved with all surgical procedures especially when they involve a prosthetic device. Such risks are significant and have to be considered over longer follow-up time periods. While some risks may be minimal, others are potentially devastating for both patient and surgeon.  Regardless of estimated likelihood, these all should be discussed in detail with patients undergoing aesthetic surgery. They generally pertain to surgical complications and aesthetic outcomes.


1. Haematoma:

This is uncommon with a range of 0-6.7%% risk but must be evacuated. Many authors have noted persistent haematoma or significant seromas lead to capsular contractures.

2. Device failure:

More recent generations of implants have proved to be more reliable, as saline implants undergo approximately 4% deflation over the first 10 years.

3. Infection and exposure:

This is a dreaded complication for both patient and surgeon. The reported rates of proven infection are between 0- 2.6%. Traditionally, the implants were removed and the patient was prescribed antibiotics. However recently, salvage procedures have become more common. These range from closed system antibiotics irrigation, conservative wound care and passive drainage in addition to systemic antibiotics. The more aggressive end of the spectrum involves exchange of the implant and provision of coverage with muscle or using posterior capsule.

5. Late seromas:

Appearance of a late seroma in an augmented breast is a source of concern for both patient and surgeon alike. Its management hinges on surgical principles and judgement.  This relates to the three principle causes: idiopathic, infective and neoplastic. If a patient presents with a new onset late seroma an ultrasound guided diagnostic aspiration is mandatory.


These include capsular contractures; malposition of implant; implant visibility/palpability/rippling; sensory and asymmetrical position changes to the NAC; breast size asymmetry; contour deformities; galactorrhea; skin stretch deformities; glandular atrophy over time; and need for device change with passage of time are salient in the discussion with the patient.

1. Rotation:

This is not a problem with traditional implants. The anatomical implants, have the advantage of filling the lower pole and especially useful with patients with mild ptosis, but not suitable if preferring augmentation mastopexy. However, up to 1% of anatomical implants undergo rotation in their pockets which requires secondary corrective surgery.

2. Malposition:

This is the second most common problem associated with breast augmentation and one of the most common reasons for revisional surgery. This occurs in about 1.2-1.6% of cases. Malpositioned implants can be difficult to treat. The implant may be displaced in any direction.

3. Wrinkling/rippling:

This is most commonly reported with saline implants, particularly in textured subtypes. It was not related to whether the implant was under-filled, recommended fill or overfilled.

4. Asymmetries:

All breasts are asymmetrical, therefore, preoperative observation and documentation is good practice. The patient is made aware of these differences preoperatively making asymmetries as a result of augmentation more acceptable.

5. NAC sensory changes:

These are more common in peri-areolar approaches. In the normal course of an infra-mammary or trans-axillary approach, transient altered sensation may occur. Generally it is considered that permanent changes are more common when implants larger than 350cc are used.

6. Scar formation:

Keloid and hypertrophic scar formation need to be discussed with the patients preoperatively.


Your relationship with your surgeon and medical team is an integral aspect of your care. It is a journey that patients should take with good knowledge and consideration, having nothing but the utmost confidence in their ability to deliver outstanding results.

Here at Panthea, we are dedicated to being there for every step of the journey with you. Whether you’re looking for a breast lift or augmentationrhinoplastytummytuck or eye lift surgery, get in touch with our Sydney or Canberra team to book your initial consultation.

Dr Rostam D Farhadieh
BSc(Med)Hons, MBBS, MD, EBOPRASF, FRACS(Plast), FRCS(Plast)
Plastic & Reconstructive Surgeon
Clinical Senior Lecturer
University of Sydney Medical School
Australian National University Medical School

Dr Ross Farhadieh
Dr Farhadieh is an internationally renowned Australian qualified and trained Plastic Surgery. He holds fellowship qualifications in Plastic Surgery from Royal Australian College of Surgeons, Royal College of Surgeons (England) as well the European Board of Plastic Reconstructive Aesthetic Surgery. He has multiple clinical subspecialty fellowships in Cosmetic, Pediatrics as well as Microsurgery from World Leading institutes in London.
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