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First, the good news is that no liquid silicone is still on the market in the U.S. So that means, currently, every FDA approved silicone implant in the US is silicone gel.

Second, the term "gummy bear" is not technical and therefore has no specifications (I am an engineer so I like universal, clearly defined, industry wide specifications). It has no useful meaning as it doesn't refer to a specific brand, style or type of implant and just confuses patients. It was coined by a plastic surgeon to differentiate between older 1st-3rd generation liquid silicone, and the then new (4th generation) gel implants being trialed in the early 1990's. It now is inaccurately used by some to refer to the thickest "form stable" gel in anatomic implants, but since that is inaccurate the confusion only deepens. Even worse, most recently, Allergan has trademarked the term "Gummy" in reference to their newest round Natrelle Inspira Cohesive implants with 5th generation silicone gel.

However, not all implants are created equal. Dr. Feldman exclusively uses Allergan Natrelle implants and here's why.

There are currently three brands of implants approved for sale in the U.S. Both Allergan and Mentor manufacture their products, while Sientra simply puts a Silimed implant into a Sientra box. Sientra is in the process of FDA approval to manufacture their own implants in the USA, which will be a huge improvement in quality control of their device, as Sientra/Silimed recently had contamination issues leading to a FDA review and voluntary sales moratorium from the Brazil Silimed plant. During that moratorium, the Silimed factory in Brazil burnt to the ground, and now Sientra has resumed selling implants from their old inventory without another manufacturing facility online. In my opinion, the company handled the situation poorly, leaving both surgeons and patients in the dark, offering little information in Friday afternoon press releases and no direct communication hotline for concerned patients, directing all responsibility to the surgeons offices. As such, Dr. Feldman is not comfortable using Brazilian Silimed manufactured Sientra implants. Allergan Natrelle brand implants have a failure rate 3x lower than Mentor implants, as Mentor's shell is thinner. Think about those thinner bargain brand garbage bags you tried and what a mess that was! Allergan silicone has only 8% failure at 10 years versus Mentor's 25% failure. That's 1 in 4 woman with Mentor! Most competitors are using Mentor because they're cheaper, but Dr. Feldman refuses to put them in due to their inferior durability and high failure rate. Additionally, Mentor also does not have as many new implant options, like high fill ratio Allergan Natrelle Inspira, or even newer Allergan Natrelle Inspira Cohesive implants, to reduce rippling and deliver more superior fullness which gives the "new normal, red carpet cleavage push up bra" look most patients are requesting. In fact over 90% of Dr. Feldman's patients are selecting Allergan high fill ratio Inspira implants.

Now for the complex details: Silicone breast implants can have 1) Varied gel thickness or cross linking of molecules, 2) Round or Anatomic shape, 3) Smooth or textured shell and 4) Variable fill ratio. 

Silicone Gel Thickness

Again all silicone gel implants in the U.S. are cohesive by definition. Then there are highly cohesive (thicker gel) or ultra-highly cohesive “form stable” gel.

Gel << Cohesive Gel << Ultra Highly Cohesive Gel

Softer more natural -------------------------->Very Firm and less natural

Higher rippling potential ------------------------> Less Rippling potential

The thicker the gel, the less rippling potential, but the firmer and less natural the breast. So in the case of gel thickness, more is not always better as like everything else in life its a tradeoff.

Allergan Natrelle Classic and Allergan Inspira have the same shell and same 4th generation gel, but the Inspira has a higher fill ratio (see below). The newest addition Allergan Natrelle Inspira Cohesive takes the ultra cohesive gel from Allergan 410 form stable, and puts it into the same shell and fill ratio as Allegan Natrelle Inpspira, giving a very nice feel, and round shape with the upper pole fullness, roundness and lack of rippling previously only available in an anatomic implant. The Inspira Soft Touch is gel thickness between the classic/Inspira and the Inspira cohesive.

Silicone Implant Shape

Then there are round and anatomic shaped implants. Each patient will have their own view on these and it has a lot to do with their age range, demographics and desired result. The vast majority of breast augmentation patients want full round, cleavage and therefore they would be disappointed with an anatomic shape. If you desire a more discreet look an anatomic shaped device may be a consideration, but they only come in thickest gel, condemning you to a very firm, less natural, feeling breast, and must have a textured shell to prevent rotation, thereby introducing a unique risk of developing ALCL, a very rare type of lymphoma associated with textured implant shells. A conservative, lower profile, round silicone implant can also give the natural teardrop shape, but with a more natural feel and smooth shell to avoid ALCL risk. Lastly, studies indicate no difference in appearance between a properly sized anatomic and conservative profile round device, as has been Dr. Feldman's experience.

Smooth vs. Textured Shell

Textured silicone breast implants were introduced in an attempt to reduce capsular contracture by "disorganizing" the scar. Studies have been mixed about whether this theory is true in patients. Sientra likes to qoute their own study showing slightly less risk of contracture with textured devices versus smooth, while ignoring numerous other studies conducted since the 1990's showing mixed results. This makes sense as I beileve early contracture has to do with blood in pocket, and is independent of device properties in first 6-12 months. Studies are mixed due to surgeon and patient compliance variability. It also contradicts the low level infection theory of contracture, as the textured devices have a greater surface area and are therefore more susceptible to low level infection, which would increase, not decrease, contracture risk and this is now a leading theory in why ALCL development is so closely related to implant texture. I also am hesitant to blame infection rather than the device itself as I would still expect some ALCL cases to develop in smooth devices with documented infections but it's been exclusive to textured shells!

Since reduction in contracture never panned out, nowadays texture has more to do with trying to keep anatomic devices in the proper orientation. Imagine an upside anatomic teardrop implant. The textured shell itself is thicker and less pliable when manufactured and the devices move less so it can be a firmer and less natural breast implant, many times a negative, but in the case of a lift or certain anatomy may be beneficial. Although EXTREMELY rare it bears noting that 90% of cases of ALCL reported have been with textured implants in place at time of diagnosis, and ALL cases had textured implants at one point prior to diagnosis. So because it's, in my opinion, still just a theoretical benefit for the vast majority of primary breast augmentation patients, and may cause unique complications, Dr. Feldman uses implants with smooth shell almost exclusively, unless a patient specifically requests the textured devices.

Fill Ratio

The Allergan Inspira line and Sientra 106 line is the same gel and shell as the Natrelle line and 105 line respectively (meaning cohesive) but is filled approximately 5-7% more giving a “fuller” look without as much volume as the next style up. Additionally, It will keep more of the implant volume in the upper portion of your breast longer. It also has less rippling potential, a big positive in extremely thin patients, without as much increase in firmness as thicker gel. My thinner patients are really moving towards the Allergan Inspira for less rippling and more durability of superior fullness. For those patients who are extremely thin and want maximum roundness and pop, the Allergan Inspira Soft Touch and Cohesive are the newest and best options.

Ultimately, no breast implant manufacturer has proven that their device looks or feels better once implanted despite all the marketing hype. Anytime there are many choices, it is because they all have positives and negatives. The implant manufacturers prey on the unknowing consumer to pick a device with flashy advertising marketing campaign strategy.

I make specific recommendations to each and every of the 500+ augmentation patients I see annually based on: 1) dimensional planning 2) expressed goals 3) amount and quality of tissue to hide the implant.

Only a board certified plastic surgeon specializing in breast augmentations (meaning they do 300+ a year) will have the expertise, knowledge and experience to understand and explain these subtle differences to you. Don’t trust your result to an office that gave you a video, booklet or patient coordinator rather than the surgeon to answer these important questions about silicone breast implants!

Read about the different profiles of implants and dimensional planning here!

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