A Survey of Attitudes of Ontario Plastic Surgeons Leading up to the Return of Silicone Implants

Sir: The government of Canada introduced round silicone gel implants to the Canadian market through the Special Access Program in 1999. Anatomical silicone gel implants became available through the Special Access Program in 2000. There has been a large increase in the use of silicone implants by Canadian plastic surgeons since the Special Access Program reintroduced them into the Canadian market in 2000. This increase is consistent across all provinces in Canada. The most dramatic increase in use has been for breast augmentation (Fig. 1).Fig. 1.: Silicone implant use in Ontario from 2000 to 2005 according to type of surgery.Health Canada lifted the restricted use label in October of 2006, granting licenses to Allergan, Inc. (Irvine, Calif.) and Mentor Medical Systems (Santa Barbara, Calif.) to market their silicone gel implants in Canada.1 The U.S. Food and Drug Administration quickly followed suit in November of 2006, also approving the marketing of silicone gel implants made by Allergan and Mentor for breast reconstruction and augmentation.2 A survey tailored to practicing plastic surgeons in Ontario was designed to evaluate surgeons’ attitudes toward the use of silicone implants for breast reconstruction and augmentation procedures. There was a 64 percent (89 of 140) response rate to the survey. Although silicone implants were the most common preference for reconstruction patients (46 percent), saline implants (21 percent) and autologous tissue (30 percent) were also commonly indicated as preferences. Surgeon preferences were more evenly divided for their augmentation patients, as 45 percent preferred silicone implants, 45 percent preferred saline implants, and 10 percent indicated they made their choice based on the patient’s preference. Many surgeons felt that shape (54 percent), consistency (78 percent), and durability (41 percent) were benefits of silicone implants. Few surgeons (<3 percent) rated these qualities as advantages of saline implants. However, 75 percent of surgeons listed other advantages of saline implants, including a smaller incision for insertion, less patient anxiety, and less expense for the patient. Surgeons were asked to consider the following earlier controversies surrounding silicone implants: Increased cancer risk Increased risk of connective tissue diseases Increased incidence of fibromyalgia Existence of systemic silicone syndrome The majority of surgeons currently feel that all of these issues are likely either false or will be proven to be false. Surgeons were then asked how much these issues currently influence their decision to recommend silicone implants to either reconstruction or augmentation patients. With regard to the reconstruction patients, 38 percent feel these issues do not at all influence their decision to recommend silicone implants. However, 17 percent feel these issues affect their decision to recommend silicone implants greatly, and 33 percent feel they affect their decision moderately. With regard to augmentation patients, 36 percent feel these issues do not at all influence their decision to recommend silicone implants. However, 20 percent feel these issues affect their decision to recommend silicone implants greatly, and 39 percent feel they affect their decision moderately. Leading up to the release of silicone breast implants in Canada, plastic surgeons in Ontario had been using increasing numbers of silicone implants. This seems to reflect increased confidence in the safety of silicone implants. Many plastic surgeons feel that silicone implants have advantages over saline implants, including shape, consistency, and durability, which also may in part account for the resurgence of silicone implant use. We recognize that since Health Canada and the U.S. Food and Drug Administration have made silicone implants more accessible, some of the concerns noted in our survey may no longer be present. Laura Snell, M.D. Nancy Baxter, M.D. John L. Semple, M.D. Sunnybrook Women’s College Health Center Toronto, Ontario, Canada DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned or implied in this article.

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