When Amanda Johnson began to consult plastic surgeons about breast reconstruction after a double mastectomy, she ran into major difficulties.
"The plastic surgeon I went to was not willing to implant silicone," said Johnson, 52, of San Diego. Johnson, an operating room nurse, knew what happened to saline implants with time. "They become hard as rocks," she said. "When you go to the beach, you have to dig a hole just to put your breasts in when lying down."
Johnson said she was given few options, and eventually consulted a different surgical center that offered silicone as well as saline implants.
"There are various ways to reconstruct a breast," said Dr. Anne Wallace, director of the breast care unit at University of California San Diego, who eventually performed surgery on Johnson. "It really depends on the woman."
Breast reconstruction can take many forms. Fortunately for breast cancer survivors today, better treatments mean that mastectomies are in decline. And even when a mastectomy is necessary, in some cases tissue from a patient's abdomen can be used to reconstruct a breast. If that is not possible, doctors then turn to implants to recreate breasts.
Breast implants are silicone sacks filled with either silicone gel or saline (salt water) fluid.
The use of silicone, though preferred by many women, has raised concerns in the past. The Food and Drug Administration (FDA) pulled silicone implants from the market in 1992 due to fears they could rupture, but made the decision to allow their use again in 2006.
"In 25 years of experience and review, we can find no advantage of the saline over the silicone," said Dr. William Wood, a professor in the department of surgery at the Emory University School of Medicine.
In addition to such safety findings, many women seek out silicone for how it makes them feel. "Silicone creates a much softer, more pliable breast," said Wallace. "It feels more like the real thing."
Even though they are legal, doctors must fill out extra paperwork when they implant silicone and must submit their patients to biannual breast MRIs.
Wallace said that the rate of rupture in an implant is 0.3 percent for the first five years -- quite low by most standards. But while a rupture in a breast implant is rare and not dangerous to a woman's health, it can cause painful scar tissue or disfigurement of the breast.
Saline implants are not immune from potential problems either. They can also rupture or leak, and the lifetime of either implant is only about 15 years.
Economics may be at the root of some surgeons' hesitation to implant silicone. "I think the real reason some hospitals don't give women the option is the cost," said Wallace. "Silicone is two or three times more expensive than saline."
Other doctors agree that patients who seek second opinions about breast reconstruction are not alone.
"We see many patients for second opinions because their surgeons do not offer immediate reconstruction," said Dr. Christine Teal, director of the breast care center at the George Washington University Hospital. "We offer it to all patients who are not expected to need postmastectomy radiation."
For many women, having a proper, healthy breast reconstruction can help put them on the road to psychological recovery from cancer.
"Breast reconstruction is part of the treatment for breast cancer," said UCSD's Wallace. "These women need it as much as chemo or tamoxifen."
If a patient feels like she is not getting the answers or the options she would like, there are legal ways to request more. According to Emory University's Wood, a patient should ask about the options, and then ask about other surgical centers.
"Often options that are inappropriate by virtue of body habitus are not reviewed by reconstructive surgeons as they are not options for that individual," he said. "It makes sense to review them and explain why they are not good options."
For Johnson, getting the look and feel made possible by silicone implants was so important that she went to a different surgeon, and battled her HMO to pay for the surgery.
"I was told that I should have saline implants right away, and that a surgeon could change them out later," she said.
"But I know that the first shot is the best shot when it comes to breast reconstruction, and I was not willing to have something in my body that I didn't want there."