Breast Augmentation

This course consists of 4 articles (all are below) on breast augmentation. Each article champions the benefits and defines the contraindications of each of the 4 types of procedures discussed. There are graphic photographs contained in this course.

Objectives: Upon completion of this course the participant will be able to demonstrate knowledge of breast augmentation procedures, treatments, risks, indications and contraindications including:

1) Submuscular
2) Subglandular
3) Endoscopic-Assisted
4) Expansion Augmentation

Expansion-Augmentation

The breast has been synonymous with femininity in many cultures almost from the beginning of recorded human history. While breast size seemed to vary according to the fashion of the times, it was not possible to increase or decrease the size of one's breasts in our early medical history. However, based on images from antiquity, one can appreciate that the breast has been both accentuated and diminished according to fashion over the years.

Czerny made the first recorded surgical attempt to enlarge the breast in 1895, when he attempted to transplant a lipoma from the back of an actress to her breasts. The long-term results of this procedure can only be guessed at. Gersuny tried paraffin injections in 1889 with disastrous results. In our recent history, various creams and medicaments have been tried to increase bust size, and Berson in 1945 and Maliniac in 1950 performed a dermafat flap. Pangman introduced the Ivalon sponge in 1950, and various synthetics were used throughout the 1950s and 1960s, including silicone injections. All of these attempts resulted in long- and short-term disasters.

In 1963, Cronin and Gerow developed the first silicone gel breast implant with the Dow Corning Corporation, ushering in the era of reliable breast augmentation. Various types of silicone gel implants then were developed by manufacturers all over the world. Inflatable saline implants and others containing a combination of gel and saline came into use in the 1970s. In 1982, Radovan developed the first generation of temporary tissue expanders for reconstructive uses, and the concept of "tissue expansion" was born.

In 1984, Becker, in conjunction with the Mentor Corporation, developed the first permanent tissue expander designed specifically for the breast, primarily for breast reconstruction after mastectomy. The Becker expander soon found use in breast augmentation in the late 1980s, giving rise to the concept of expansion-augmentation. The use of this implant was curtailed after the implant crisis in 1991, but was supplanted with the Spectrum implant, a permanent saline expander with the Becker valve, fill tube, and reservoir system. While the gel/saline Becker is still available with FDA restrictions on usage, primarily the cost makes it unsuitable for expansion-augmentation. It virtually has been replaced by the Spectrum saline implant, which at the time of this writing, has no peer as a combined permanent breast implant and expander.

INDICATIONS FOR THE PROCEDURE

While the process of breast augmentation is a fairly straightforward and simple procedure, many cases involving either size, shape, symmetry, or scarring lead to unpredictable and undesirable results. In these instances, expansion-augmentation offers a viable and predictable alternative.

Size

Saline augmentations of the breast have been more common in the US since the FDA banned silicone gel implants in 1991. At first, surgeons treated saline augmentations as if they were the same as gel, but time and experience taught us that saline and gel implants behave differently. Some features of the saline implant are superior to those of gel, but the issues of feel, palpability, and rippling seem to mandate that this implant be placed beneath the pectoralis muscle rather than above it. In addition, the texturing of the implant surface that reduced the gel implant's high fibrous contracture rate in the subglandular position proved to be no advantage for saline and may even be a contributing factor in implant rupture through fold failure.

In the submuscular position, size of augmentation can become a deciding factor because of the relatively noncompliant nature of the muscle cover. Depending on the width of the woman’s chest and the bulk and strength of the muscle as well as the tightness of the overlying breast and skin, the maximum augmentation could vary from 250-450 cc. Once the maximum fill is obtained in a submuscular augmentation, the breasts assume a spherical shape and become firmer than a realistic breast, thus limiting the aesthetic result. This problem can be compounded when performing a secondary augmentation, ie, changing from a subglandular pocket to a submuscular one because of scar tissue (fibrous capsule) overlying the pectoralis muscle.

The concept of tissue expansion is that as tissue is gradually stretched, it accommodates. If the tissue is stretched beyond a certain endpoint for a period of time and then the stretching force is reduced, redundancy results. This concept is employed in the expansion-augmentation technique. Implants are placed at surgery in the same fashion as any saline implant except that the microreservoir is attached to the fill tube and implanted under the skin. It is decided preoperatively the size required to achieve the desired result. The implant is initially filled at surgery to a comfortable size, and weekly expansions of 60-120 cc are performed, beginning after the first postoperative week. The reservoir is placed near the incision for later ease in removal without an additional scar.

When it is decided preoperatively that a certain size is required to achieve the desired result, the expansion is performed first to the desired size, then beyond that size for a period of time. The excessive fluid is then drawn out of the implant, creating the redundancy, which is expressed in the shape and softness of the resulting breast. The reservoirs are usually removed shortly after completing the expansion process, under local anesthesia, but Berrino leaves the reservoirs in for an extended period for later adjustment of fluid volume. The removal can be performed in the treatment room or operating room under local anesthesia through the prior incision to prevent creating a new scar. Using this slow stretching of the breast, submuscular breast augmentation has virtually no size limitations. Additionally, with this technique, the patient becomes an active participant in the outcome of her own breast augmentation and ultimately will be happier with the result.

Shape

The shape of the breast during an expansion-augmentation can be affected by the amount of redundancy created. Usually, shape is titrated with softness. The softer the resulting breast, the more natural it looks and the more like a real breast of a similar size it becomes. The firmer the breast, the rounder it appears. This titration occurs at the end of the process when removing the excessive fluid. It can be affected by the ultimate size of the implant versus the manufacturer’s recommended size, ie, if the final size is larger than the recommended final fill, the implant will naturally be more spherical. Further, it can be affected by the final volume obtained versus the amount of fluid removed, even within the manufacturer’s recommendations. The author prefers to remove no less than 100 cc and no more than 200 cc, and it is within this envelope that the titration of shape occurs.

Symmetry

The expansion technique finds its greatest success in overcoming breast asymmetries that can range from simple volumetric differences to much more complex issues involving volume, nipple position, base width, and ptosis or pseudoptosis. The artistic usage of an expandable implant can result in much greater breast symmetry, even in very difficult cases, without resorting to unilateral mastopexies or nipple lift procedures, which in themselves destroy symmetry. If the breast with the higher nipple is overexpanded to a greater volume and for a longer time than the lower one, after release of the fluid, that nipple will fall (farther) than the other, often creating greater symmetry. This fall is quite striking if the expansion occurs in the subglandular space on the affected side, but some descent is also possible in the submuscular position. Other asymmetries can be "stretched out" as well and include differences in roundness, inframammary crease position, size, and shape.

Scarring

The shape of the breast can be adversely affected by prior scar tissue from any number of causes, with fibrous encapsulation as the most frequent cause. It is a well-known phenomenon that persistent stretching overcomes scar tissue and changes tissue shape. In the breast, scar tissue can limit the roundness of contour, which is so attractive. Expansion can restore proper shape to breasts that have become misshapen because of scar. Further, if the problem is repeated fibrous encapsulation, overexpansion for a longer period of time, sufficient to obtain mature scar tissue, can overcome a recalcitrant fibrous capsule. The tuberous breast and pseudoptotic breast have an abnormally high inframammary crease that can result in a double bubble effect if one simply places a submuscular implant below the natural inframammary crease. Expansion can overcome this problem.

Another extremely useful feature of the expander is for the treatment of capsular asymmetries created by prior breast implant surgery. When performing an internal capsulodesis with a running or interrupted suture technique, the expander can be placed into the pocket greatly underinflated to avoid putting tension on the repair. The implant can remain underinflated for 3 weeks to allow for wound healing and then be filled. Overfilling then overcomes slight irregularities in the contour that may have been created by the internal capsulodesis.

RESULTS

Please see the photograph series at the end of the chapter. The series illustrate the results obtainable with the expansion-augmentation technique.

With expansion, one can make extremely large breasts, if requested, as the manufacturer’s recommended volume can be exceeded. In addition, always expect the patient to request a larger volume at the end than in the beginning. In the patient in Picture 13, the request was for a 2-cup increase and the estimate was for a total of 850 cc, using a smaller implant to get greater roundness. Final volume was 1130 cc.

COMPLICATIONS

The charts included reveal that since 1993, the author has performed breast augmentations on 480 total patients or 960 implants. Of these, 131 were expander patients (262 implants) and 349 standard implant patients (698 implants). The complications studied were deflations, infections, capsular contracture, and reservoir extrusions. The results were as follows:

Deflations

There were 21 total deflations in this series, 8 of which were expanders and 13 were standard implants. Therefore, the total deflation rate was 21/960, or 2.1% overall. The deflation rate for standard implants was 13 of 698, or 1.86% over this 5-year period, and for expanders it was 8 of 262, or 3.05%. Total deflations = 21/960 = 2.1%

Infections

Total infections = 6/960 = 0.63%

5/960 = 0.52% for standard implants

1/960 = 0.1% for expanders

Capsular contractions

There were 25 total implants whose Baker rating was higher than 2 (25/960) for an overall rate of 2.6%. Of these, 15 were in the standard implant group (15/698) for a rate of 2.1% and 10 were in the expander group (10/262) or 3.8%. The slightly higher rate for expanders can be partially explained by the patient's desire to sacrifice size for softness.

Reservoir extrusions

2/262 = 0.76% (expanders)

CONCLUSIONS

The expansion-augmentation technique is a useful adjunct to breast augmentation in selected patients and should be considered a part of every plastic surgeon’s armamentarium. In difficult cases involving implant malposition, recurring fibrous capsular contracture, or asymmetry of volume or breast shape, these implants can make a very difficult case almost simple. Patients accept this technique readily and are uniformly happy with the results and are especially happy to be a part of the decision-making process where size is the issue.

IMAGES

Caption: Picture 1. Chart 1: Implantations from 1993-1999

Picture Type: Graph

Caption: Picture 2. Chart 2: Complications after 5 years

Picture Type: Graph

Caption: Picture 3. A 34-year-old patient with A cup requesting C cup. Her volume is approximately 200 g of breast tissue, thus will require approximately 600-200=400 cc total. A 425+ Spectrum was chosen to allow for further increases. The postoperative views are after overexpansion for 6 weeks from the last fill with a volume of 660 cc, just prior to release of excess fluid on right and after release of 120 cc on left. Final volume is 540 cc. Note the softening effect. The profile views breasts prior to fluid release. Note excess fullness of upper pole of left breast. Compare with profile views on left after release of 120 cc.

Caption: Picture 4. Patient is a 32-year old nulliparous female with 34AA cup. She wishes to be a full C cup. Estimate of volumetric requirements is 550-600 cc. A 475+ Spectrum was chosen. Postoperative views reveal a final volume of 660 cc after expansion to 780cc for 6 weeks.

Caption: Picture 5. A 25-year old with B cup requested D/DD breasts. The preoperative estimate was 500-600 cc, and a 575+ Spectrum was used. The postoperative views are with a final volume of 600 cc after expansion to 750 cc (6 weeks).

Caption: Picture 6. A 28-year-old patient with slight breast asymmetry (R>L). Currently AA cup, she requested C/D cup. Estimate is 650 cc total volume with more required on left side. 575+ Spectrums were used and filled to 720 cc R and 780 cc L. Final volume is 600 cc on R and 660 cc on left.

Caption: Picture 7. A 35-year-old patient with A/AA breasts requesting a mid-C cup. The preoperative estimate was 500-550 cc and a 475+ Spectrum implant was used and filled to a total of 650 cc for 6 weeks. 120 cc were removed for a final volume of 530 cc.

Picture Type:

Caption: Picture 8. A 30-year-old patient with 700 cc encapsulated implants in subglandular position. Nipples are ptotic to 26 cm from the sternal notch. The tissue is paper thin because of implant position and attenuation from stretching. She refused to have a mastopexy because of her profession (exotic dancer). An exchange of pockets from subglandular to submuscular (without capsulectomy) was performed. The skin and nipple-areolar complex (NAC) were supported with tape dressings and bra for approximately 3 weeks. A bilateral inferior capsulotomy was performed at the end of the procedure. The temporary total volume was 1000 cc with a final volume of 850 cc. The implants were overfilled by 150 cc, as the patient preferred the round look to the natural appearance. Please note that the nipples have elevated by scar contracture of the subglandular pocket from 26 cm to 23 cm.

Caption: Picture 9. A 34-year-old patient with prior augmentation. Right implant capsule was too lateral and left implant crossed over midline. Also, there was a prior attempt to medialize the left nipple. After bilateral internal capsulodesis, the expanders were filled to only 200 cc and were not expanded for 3 weeks to allow for healing of the repair. Expansion resumed after 3 weeks to round out the capsule and overcome adverse scarring. They were filled to 720 cc and the final views are at 620 cc.

Caption: Picture 10. A 32-year-old patient with prior augmentation using small implants, R subglandular and L submuscular. Right nipple is 22 cm from sternal notch and left is 21 cm. Implant “knuckle” visible R medial breast area. Plan was for R Benelli lift and bilateral expansion (submuscular) to achieve volumetric and shape symmetry. Her prior implants were 175 cc and she wished to be a C cup. There was a volumetric difference between the breasts of perhaps 75-100 cc. A 475+ Spectrum was chosen for both sides. The final views are at 4 months total. Filled to a total of 660 cc on both sides. The final volume is 510 cc R and 530 cc L side.

Caption: Picture 11. A 24-year-old patient with tuberous breast deformity and marked tissue deficiency on the left side. She wanted a full C cup. A 375-450 cc Spectrum was chosen. Patient was told to expect an inframammary dent. The tissue deficiency of the lower pole of the left breast is very evident at 2 weeks. However, with continued stretching, the deficit is minimized visually to a great degree. The total fill volume was 700 cc for 8 weeks, and the final volume was 520 cc after release of 180 cc.

Caption: Picture 12. A 29-year-old patient with A cup and pseudoptosis who wanted full C cup and upper pole fullness. Size estimate was approximately 400 cc total (perhaps more for upper pole fullness). A 375+ Spectrum was chosen. Total fill was to 570 cc for 6 weeks with removal of 180 cc to a final volume of 390 cc.

Caption: Picture 13. The final pictures are of a 27-year-old patient who had a prior breast augmentation with 450 cc implants. She requested an E or F cup from a D/DD. The increase in size requested was probably only 300 cc, so a 475-570 cc Spectrum was used. The total fill was to 1250 cc, and final volume was 1130 cc.

Breast Augmentation, Subglandular

INTRODUCTION

One of the great debates in plastic surgery has focused on whether to place breast implants over or under the pectoralis major muscle. This author’s strong feeling is that in most instances, the implant should be placed in the subglandular position, that is, over the muscle.

History of the Procedure: Breast augmentation first was attempted in the early 1900s. The site of placement was always subglandular. Everything from ivory to ebony to paraffin was implanted and, of course, rejected. In the 1950s, Ivalon sponges were used. Although they were biocompatible, fibrous tissue grew into them, making them extremely hard. Breast augmentation was begun in earnest in the mid-1960s when silicone implants were introduced. Again, the placement always was subglandular.

The major problem with breast implants always has been hardness. The implants themselves do not become hard; the problem is that the human body recognizes that the implant is a foreign object. Since the human body cannot reject the implant (silicone had no active binding sites), the defense mechanism is for the body to wall it off with a membrane consisting of myofibrils and collagen. This commonly is termed a capsule. If the capsule contracts around the implant, the consequence is similar to squeezing a balloon partially filled with water—it feels hard. This is known as fibrous capsular contracture. Why the capsule contracts in some patients remains a mystery. Even more mysterious is the fact that it frequently occurs in only one breast and not the other.

The early silicone implant had backing made of Dacron that was meant to hold the implant in place. What was not realized for several years was that the Dacron caused a severe tissue reaction, resulting in extreme capsular contracture. In the late 1960s, the idea of putting the implant under the muscle was introduced. This placement was popularized in the mid-1970s because of the belief that the breast felt softer with subpectoral implantation. Unfortunately, the characterization of the degree of hardness is difficult to quantify. Although the Baker system of classification is widely accepted for this purpose, determining just how much firmness a breast may have is still a very subjective matter, and therein lies the problem of studying which procedure minimizes the problem.

Problem: The argument for subpectoral placement is as follows:

The muscle covers the implant, thus any capsular contracture (breasts that feel hard) is less common.

For the same reason, rippling (wrinkling) of the implant is less apparent.

Mammograms are more accurate.

In very small-breasted women, the outline of the implant is less visible.

The surgery takes less time.

The argument for subglandular placement is as follows:

The breast is obviously over the muscle, thus the implant belongs there.

Because of this, subglandular placement most often looks more natural.

Because the muscle covers only one third to one half of the implant when the implant is placed below it, minimal advantages exist in placing the implant there. (This does not apply for the rarely performed true submuscular implant that also uses the serratus anterior muscle for coverage.)

Because most of the implant is not covered by muscle when placed below it, minimal advantages exist in placing the implant there. Only a slight diminution of the incidence of capsular contracture and implant rippling occurs.

Subpectoral placement requires cutting the muscle insertion. Because of this and/or the pressure of the underlying implant, the pectoralis muscle becomes very atrophic and virtually is destroyed. The assertion that the implant "falls" into a more natural position within weeks of the surgery is false. Actually, the muscle is atrophying, causing the diminution of the initial upper pole fullness.

If any degree of ptosis is present, a subglandular implant lifts the breasts much better.

A properly performed mammogram shows 95% of breast tissue.

Lower risk of postoperative bleeding is involved.

Significantly less postoperative pain occurs.

The procedure can be performed with intravenous sedation and local anesthesia.

Nevertheless, approximately 50-60% of plastic surgeons perform submuscular implantations. This author places approximately 2% of implants under the muscle, usually for very small-breasted patients.

Frequency: Micromastia is a very common occurrence.

Clinical: Derive the patient’s motivation and expectation. Be wary of the patient who wants the surgery to please her partner. Try to match the patient’s expectation to the effects that can be achieved. When a patient asks for very large breasts, the author inquires if she wants a natural appearance. The answer is almost always affirmative. In that situation, the author states that he will make the breasts as large as possible and still have them appear natural.

On physical examination, noting any asymmetry is important, because the patient may be unaware of the problem and only note it postoperatively, thus blaming the surgeon. Differences in nipple and breast height, size, and shape are very common.

Look for stretch marks and assess their depth. Also observe any thinning of the breast tissues, since these problems cause a higher degree of rippling (wrinkling) of the implants.

Note any degree of ptosis and advise the patient regarding how much will remain postoperatively. Except in extreme situations, the author prefers not to preform a mastopexy, since most patients are satisfied with the augmentation and whatever lift it provides and do not want the additional scarring. Failing that, a nipple lift is often sufficient. Obviously, locate any breast masses or discharge. During the physical examination, discuss the patient’s desires and the size of the implant.

INDICATIONS

Micromastia (ie, small breasts) is obviously the reason patients seek an enlargement procedure. However, surprisingly, what may appear to be ample breasts to the surgeon may seem quite small to the patient requesting augmentation.

A patient occasionally requests surgery because of asymmetry.

RELEVANT ANATOMY AND CONTRAINDICATIONS

Relevant Anatomy: The female breast covers the anterior chest wall from approximately the second rib superiorly to the fourth or fifth rib inferiorly. Its upper one half overlies the pectoralis major muscle, the serratus anterior its lower one half, and some of the axillary fascia laterally.

The breast is essentially a skin organ. It is attached intimately to the skin by suspensory ligaments (Cooper ligaments). This is because developmentally it forms from the ectoderm of the anterolateral body wall, and epithelial proliferation from that site creates the gland. For this reason, opening the natural plane between the muscle and the breast is easy; an implant can be inserted into this space.

The blood supply of the breast is derived from branches of the axillary artery, the intercostal arteries, and the internal mammary artery. Few if any vessels penetrate into the gland from the underlying gland.

Its nerve supply comes from the anterior and lateral cutaneous branches of the fourth, fifth, and sixth thoracic nerves. One of the larger lateral cutaneous branches often can be visualized and preserved during augmentation surgery.

Contraindications: The one absolute contraindication to subglandular augmentation is an irradiated breast. Because of interference with the blood supply caused by radiation, a subpectoral placement is much safer.

Another reason to consider placing the implant under the muscle is very thin breast tissue, as can occur after pregnancy.

Some surgeons also believe that a subpectoral implantation should be used in extremely small-breasted patients, although the author feels this is necessary only in some patients.

Because a small amount of the breast may be obscured during a mammogram, a patient with a strong history of breast cancer probably should be augmented under the muscle, as should a patient undergoing postmastectomy reconstruction when the contralateral breast also is being augmented.

WORKUP

Lab Studies:

Perform routine blood tests, including a CBC and clotting studies, preoperatively.
Obtain a pregnancy test on the day of surgery.

Imaging Studies:

Obtain a baseline mammogram in a patient who is aged 35 years or older and who has not undergone the examination previously.

TREATMENT

Medical therapy: Despite occasional false advertising to the contrary, no drug enlarges a female breast permanently.

However, a device that stretches the skin externally is purported to cause proliferation of the underlying tissue to provide an increase of up to 1 cup size. It currently is undergoing testing as to its efficacy and the permanence of the result.

Surgical therapy: In the author's opinion, micromastia is best treated with a subglandular breast augmentation.

Preoperative details:

Thoroughly discuss the procedure and its risks with the patient during the preoperative consultation. Especially assess the patient's personality and expectations.

Inform the patient of details of what to expect before, during, and after the surgery.

Attempting to meet the patient's expectations regarding size is very important. When a patient asks for an implant that the author feels is too large, he explains why he believes that the implant would be deforming, and he informs the patient that he will place the largest implant that appears natural.

In situations in which flexibility is possible and the author is not sure exactly what the patient wants, patients are asked to bring in a picture from a magazine or lingerie catalogue to provide an idea of what they envision for themselves.

Aspirin and ibuprofen should be avoided for 2 weeks before surgery.

Intraoperative details:

If the operation is performed by means of the inframammary route (author’s preference), the incision need only be 2.5-3 cm if an inflatable implant is used.

Mark the incision preoperatively with the patient in the upright position. Place the incision in the inframammary fold, lateral to the midmammary line. The author makes no other preoperative markings, relying on judgment during the operation regarding size and placement. Postoperatively, the expansion of the skin brings the incision up on the undersurface of the breast for a distance of 1-2 cm. This keeps the scar from being visible in a bikini bathing suit. The resulting scar is almost always acceptable, and revision is rarely necessary.

Carry the incision down through subcutaneous tissue and superficial fascia onto the fascia of the serratus anterior muscle. Continue dissection superiorly over the fascia of the pectoralis major muscle to a level of approximately the second rib, as a large pocket is essential. This can be accomplished with scissors in combination with finger dissection, spreading devices, or a sponge on a stick.

Do not carry the medial dissection further than the lateral sternal border. An attempt to give the patient “cleavage” by dissecting further medially results in synmastia, an unsightly bridge of skin joining the breasts together.

The lateral extent of the pocket is a matter of judgment. The author usually makes a modest dissection to the anterior axillary line, and after the implant is in place, the finger is used to extend the lateral dissection until the outline of the implant is no longer apparent.

Meticulous hemostasis using electrocautery is absolutely essential. The author uses a fibro-optic lighted retractor for visualization. Usually the dissection is performed on one side, a few sponges are placed in the pocket, and then the other side is dissected. When returning to the first side, small bleeders are sometimes apparent and can be cauterized.

Once the pocket is dissected and hemostasis is assured, the author first places an inflatable sizer corresponding to the projected size of the implant. After filling it with air, the judgment is made regarding which size best fits the patient and addresses her expectations.

Then place the implant in the pocket and inflate it with saline. Adding anything to the saline is advised against strongly. Betadine is suspected to weaken the implant wall, and steroids are well known to cause erosion of the overlying tissue, resulting in exposure and extrusion of the implant.

The author recommends filling the implant to the maximum amount allowed by the manufacturer. The author adds an additional 5-15 cc more than that amount, depending on the size of the implant, in the belief that this helps prevent rippling of the implant. However, if too much saline is added, scalloping of the implant edges results.

The author prefers smooth-walled round implants. Textured implants have thicker shells, thus any rippling becomes much more offensive. The author also has experienced a higher incidence of capsular contracture with textured implants and serious leakage problems. Round implants are used because oval or teardrop-shaped implants that are not textured can rotate.

Close the incision in layers. Suture the superficial fascia with absorbable sutures such as Dexon or Vicryl. The author also places interrupted subcuticular sutures that are absorbable and closes the skin with 6-0 nylon. Some surgeons prefer a continuous subcuticular closure. The bandage merely covers the incision, and the author employs no other taping.

Postoperative details:

The author uses postoperative antibiotics and prescribes propoxyphene and acetaminophen (Darvocet) for pain. Aspirin and ibuprofen should be avoided for 2 weeks after surgery. Vitamin E and papaverine (Pavabid) are prescribed for possible prophylaxis against capsular contracture.

Remove sutures after 1 week.

Although the author does not require a brassiere in the first postoperative week, he has no objection to its use immediately after surgery. After the first postoperative week, a sports bra often makes the patient more comfortable for the next month.

Advise the patient to refrain from physical exercise for 3 weeks; the patient can return to work in approximately 3 days. Patients are allowed to engage in whatever activities they feel comfortable doing.

Follow-up care:

Patients are seen 1, 2, and 6 weeks postoperatively. Although they are instructed to massage their breasts after the second week, the author does not believe this is of any value.

Patients usually return on their own if they experience a capsular contracture, which can be treated with closed capsulotomy.

COMPLICATIONS

The prospective patient must be informed of the risks and possible complications of the operation.

Infection

Infection is a rare complication occurring in approximately 1 patient per 1000. It usually necessitates removal of the implant and replacement at a future date.

Postoperative bleeding

This occurs in 0.5-1% of patients. While it is not life threatening, it requires additional surgery to stop the bleeding.

Deflation

Several years ago, the author used textured implants in approximately 100 patients, and deflation resulted in 5 patients, which is highly unacceptable. Except for those 100 surgeries, the author has used smooth-walled implants in approximately 1000 patients since 1992 and has had no deflations. However, deflation is certainly a known risk and may well happen in the future due to fold faults, which are continuous flexing of the implant edge that, like repeated bending of a paper clip, can cause failure of the implant. Rarely, the filling valve can be defective.

Capsular contracture

Capsular contracture is the major problem with breast implants. If the capsule contracts around the implant, it squeezes it and makes it feel hard. This complication can be treated with closed capsulotomy, but it may recur. Many studies demonstrate no difference in contracture rates when the implant is over or under the muscle. Vitamin E and papaverine (Pavabid) are believed by some to reduce the incidence of capsular contracture. The author's incidence of capsular contracture with 2500 subglandular augmentations is less than 10%.

Rippling of the implant

Although this occurs more frequently in patients who have thin breast tissue following pregnancy or who have deep stretch marks, it can occur in any patient. Silicone implants have a much lower incidence of rippling because the gel adheres to the elastomer lining, which helps keep it from rippling. (Silicone gel implants will be allowed for all uses some day.) Hydrogel, where available, also results in less rippling.

OUTCOME AND PROGNOSIS

The implant manufacturers state that their products are not meant to be lifetime devices, but because of their long-term guarantees of replacement, they obviously hope that they will be used over the patient's life.

Overall, the author has found a high degree of patient satisfaction with subglandular placement of breast implants and recommends that approach. Whatever the complications with hardness or rippling, almost no one asks for the removal of the implants.

FUTURE AND CONTROVERSIES

As previously noted, a device that stretches the skin externally and supposedly causes proliferation of the underlying tissue to provide an increase in the size of the breast of up to 1 cup size is presently under investigation. While the author believes not many patients will opt for this device because it is cumbersome to use, he also believes that its efficacy and the permanence of the result are yet to be demonstrated.

Saline breast implants have some serious disadvantages, especially regarding how they feel and the occurrence of rippling. Hydro gel implants are presently in use in Europe and are being readied for approval by the Food and Drug Administration. In addition, silicone implants are undergoing clinical trials, and the author believes they will be available for general cosmetic use within a few years.

IMAGES

Caption: Picture 1. Breast augmentation, subglandular. A cup to large B cup

Caption: Picture 2. Breast augmentation, subglandular. A cup to C cup

Caption: Picture 3. Breast augmentation, subglandular. A cup to C cup

Caption: Picture 4. Breast augmentation, subglandular. Very small A cup to C cup

Caption: Picture 5. Breast augmentation, subglandular. Very small A cup to large B cup

Caption: Picture 6. Breast augmentation, subglandular. A cup to large D cup

Caption: Picture 7. Breast augmentation, subglandular. Small B cup to D cup

Caption: Picture 8. Breast augmentation, subglandular. A cup to Large B cup

Caption: Picture 9. Breast augmentation, subglandular. A cup to D cup

Caption: Picture 10. Breast augmentation, subglandular. This patient had previous implants behind the muscle. Same implants placed in front of the muscle

Caption: Picture 11. Breast augmentation, subglandular. This patient wanted a lift and much larger breasts. A cup and slight drooping to C cup

Caption: Picture 12. Breast augmentation, subglandular. This patient wanted a modest enlargement and less drooping. A cup and slight drooping to B cup

Caption: Picture 13. Breast augmentation, subglandular. This patient wanted a large C and less drooping. Small B cup and moderate drooping to D cup

Caption: Picture 14. Breast augmentation, subglandular. This patient wanted much less drooping. B cup and significant drooping to D cup

Caption: Picture 15. Breast augmentation, subglandular. Small B cup and significant drooping to D cup

Breast Augmentation, Submuscular

INTRODUCTION

Breast surgery is performed to enhance the size and shape of a woman's breasts. Surgery typically improves the individual's self-image. Historically, breast enlargement was accomplished by 1 of 3 methods, with varying results of success.

Inert material such as silicone and paraffin has been injected directly into the parenchymal tissue to increase breast size. This method was abandoned because of the exceedingly high incidence of both acute and long-term complications. Granulomas are frequent from this procedure, as are complications of skin loss and scar contracture producing excessive disfigurement.

Autogenous tissue injections also have been used in an attempt to enhance and enlarge the shape of a woman's breasts. Autogenous tissues, including omentum, fat, muscle, lipomas, and skin in the form of dermis and dermal fat grafts, have been used to enhance and enlarge the breasts. Results from injection of autogenous tissue have not been positive or predictable. In addition to scarring and uneven texture that may be visible in patients who have undergone tissue injection into the breasts, microcalcifications develop. This makes performing follow-up mammography on these women for early diagnosis of breast cancer impossible.

Recently, a suction pump device was used to attempt to enhance the shape of women's breasts. However, while some enlargement was noted, the overall aesthetic shape in these individuals was lacking significantly.

Implants have been used since the 1960s to enhance and enlarge the shape of female breast tissue. Currently, they are the preferred approach for augmentation mammaplasty. First used in 1964, when reported by Cronin and Gerow, silicone still is used for augmentation of female breasts. The advantages of silicone-filled implants include minimum solubility of the silicone and excellent viscosity of the material, providing an excellent feel to the breasts. Problems associated with silicone implants include capsular contracture, granulomas that develop following leaching of silicone from the implant, and migration of silicone into the axilla. Autoimmune responses have been reported regarding silicone implants in breast augmentation. These were discredited because of a number of exhaustive long-term studies that failed to demonstrate increased incidence of long-term problems in large numbers of women who underwent augmentation with silicone implants.

When the Food and Drug Administration temporarily removed silicone implants because of purported increased incidence of autoimmune phenomena, a considerable amount of interest arose regarding the use of saline implants to augment breast tissue. Saline-filled implants have been used since the 1960s. Saline is absorbed safely into the bloodstream if a loss in the integrity of the implant capsule develops. Saline commonly is used in intravenous (IV) solutions and poses no risk to patients.

Saline implants purportedly have a decreased capsular contracture rate when compared with silicone implants. However, saline has slightly decreased viscosity compared to silicone. The initial use of saline implants resulted in a high incidence of deflation (approximately 10%). Over the last 10 years, significant work by implant manufacturers to improve the integrity of implants and specifically to improve the reliability of the valvular mechanism for introduction of saline into the implant has resulted in deflation rates that are predicted to be less than 1%.

History of the Procedure: Implants may be either round or teardrop shaped. Round implants are disc shaped and exhibit equal fullness in all 4 quadrants of the breast (see Image 1). Teardrop or anatomic implants exhibit reduced augmentation fullness in the upper pole of the breast with increased fullness in the lower half of the breast (see Image 2). These implants also are narrower at the superior and inferior poles than rounded implants.

The implant capsule may be smooth or textured. Textured implants initially were developed as an alternative to polyurethane-covered silicone gel implants, which first were introduced in the early 1970s. Initial reports indicated polyurethane-covered silicone gel implants resulted in decreased capsule formation. Ingrowth of scar tissue into the polyurethane surface was postulated to break up the vector forces of scar contracture. Because of the altered vectors of scar contracture, the capsule of the scar was unable to contract to the same degree as typically present around a silicone implant; however, this theory never was proven definitively in a scientific study.

However, it became clear that polyurethane underwent microfragmentation and phagocytosis. In addition, the polyurethane possibly would break down and dissolve within the tissue locally after placement of these implants. An intense foreign-body reaction with numerous macrophages and multinucleated giant cells occurred in the capsule in some patients who had this type of implant.

Because of these problems, implants with a polyurethane-covered coat were removed from the market. The implant manufacturers, in an attempt to duplicate the potentially protective value with regard to capsular contracture in polyurethane-covered silicone gel implants, sought to increase the wall of standard saline implants to duplicate the effect noted with polyurethane. This same approach also was attempted in silicone implants. Unfortunately, results from increasing the capsular thickness with surface texturing have not conclusively decreased capsular contractures in patients undergoing breast augmentation. Reports of increased wrinkling because of placement of textured implants in individuals undergoing breast augmentation have been noted.

RELEVANT ANATOMY AND CONTRAINDICATIONS

Contraindications: Severe ptosis is a relative contraindication to surgery. Women with significant ptosis may require a mastopexy concomitantly or as a secondary procedure. Women with tubular breasts also are at significant risk of secondary procedures after the augmentation to correct residual deformities secondary to the original tubular shape of the breast. Evaluate severe associated medical conditions on a patient-by-patient basis, as with any surgery.

TREATMENT

Surgical therapy:

Placement route

Implants may be placed by a number of routes that typically vary with surgeon preference and experience. The individual's desired results may influence the site of implant placement.

Inframammary approach

An inframammary incision is the most common approach for placement of a breast implant. This approach, which entails a 3- to 4-cm incision, attempts to place the incision in or adjacent to the inframammary crease. The inframammary approach provides the most direct route and, in general, requires the least operative time for placement of the implant. Problems associated with inframammary incisions include a visible scar on the anterior surface of the breast. Additional problems center around the difficulty in placing the incision in the inframammary crease, which potentially is exacerbated with low-profile implants.

Periareolar approach

Implants placed by an incision within the pigmented areolar tissue, referred to as a periareolar incision, often result in the least conspicuous scar. However, dissection of the pocket required for implant placement is more difficult with a periareolar incision. Dissection must proceed through a portion of the breast tissue or in the subcutaneous plane. Problems with subcutaneous dissection include nodularity and inflammation. Incisions placed through the breast tissue or in the subcutaneous plane are associated with microcalcification and cyst formation. Medial placement of the periareolar implant incision within the areolar avoids the fourth intercostal nerve, which supplies sensation to the nipple and areola.

Transaxillary approach

Placing incisions in the axilla, referred to as a transaxillary approach, avoids placement of the scar on the breast. The transaxillary approach provides the worst exposure for placement of the implant, which is a disadvantage. This may be avoided using special instrumentation, including endoscopes and specific surgical instrumentation designed to aid the dissection. An increased incidence of paresthesia involving the nipple-areolar complex exists with this approach. Obtaining symmetric pockets is more difficult, and damage to the intercostal brachial nerve and subclavian venous thrombosis has been reported with this technique. Additionally, if infection results, removal of the implant may require conversion of the transaxillary incision to one of the other incisions listed above. Hypertrophic scar formation also can occur in the axilla, and the incision may be visible when the patient wears a sleeveless dress and elevates her arms.

Periumbilical approach

A periumbilical approach, involving placement through the umbilicus, can be used for augmentation of the female breast. Placement of the implant is restricted to a prepectoral plane, and this approach provides the worst control for dissection of the pockets. Superior dissection and symmetry of placement are difficult, even in the most experienced hands. Complications of hematoma or infection require conversion to one of the other incisions for implant removal. Additionally, placement of saline-filled implants through a periumbilical approach requires a special type of valvular mechanism, and long-term reliability of the valvular mechanism in these implants has not been fully clarified, at least to the author's satisfaction.

Implant placement

Implants may be placed directly beneath the mammary gland or in a plane below the pectoralis major muscle. Advantages attributed to placement below the gland include ease of dissection, predictable sizing and contouring, and satisfactory results provided capsular contracture does not occur. Placement of larger implants in a subglandular position than in submuscular placement also is feasible (see Image 3).

Submuscular placement of implants was developed in response to problems associated with subglandular placement, specifically, capsular contracture and visibility of the edge of the implant (see Image 4). Additional benefits attributed to submuscular placement include reduced sensory changes in the nipple, decreased rates of capsular contracture, and ease of interpretation of mammographic studies. The submuscular plane is avascular, and incidence of hematoma may be reduced by placement in the submuscular plane.

Disadvantages include potential limitations on the size of the implant, increased postoperative pain, and the possibility of lateral displacement of the implant. In addition, obtaining significant cleavage is more difficult with submuscular placement. If significant cleavage is desired, detach the inferior portion of the pectoralis musculature from its sternal attachments (see Image 5). This results in increased postoperative discomfort.

COMPLICATIONS

Hematoma

The frequency of hematomas is less than 2%. Associated symptoms of hematoma typically are unilateral pain, swelling, and occasionally fever. Hematomas may develop slowly without symptoms or rapidly with symptoms. Small hematomas may resolve without intervention, but large hematomas require drainage. Often, delaying drainage until liquefaction of the clot has occurred is preferable. However, if the hematoma is painful or large, drain it immediately.

Infection

Incidence of infection is approximately 2%. Infection typically becomes apparent 7-10 days postoperatively but may manifest at any point. Typical presenting symptoms of infection include swelling, discomfort, pain, drainage, and cellulitis overlying the breast. Typically, drain and irrigate the wound. Removal of the implant may not be necessary, particularly if a periareolar incision was used with initial surgery. Prescribe antibiotics immediately. If the implant is not removed, infection may result in severe capsular contracture. If the implant is removed following infection, it typically is replaced in 3-6 months. Staphylococcus epidermidis or Staphylococcus aureus commonly may cause infections.

Sensory changes

Changes in nipple-areolar sensation are common postoperatively in patients who have undergone breast augmentation. Most patients exhibit a temporary dysesthesia, which tends to resolve in a period of months. However, a small percentage of individuals may present with long-term sensory changes in one or both nipples following breast augmentation. An increased incidence of sensory changes is noted with transaxillary augmentation, since this approach directly crosses the fourth intercostal nerve, which supplies sensation to the nipple-areolar area.

Scars

Hypertrophic or keloid scar formation is uncommon following breast augmentation. The lowest incidence of hypertrophic scarring appears in periareolar incisions. The presence of a hypertrophic scar in inframammary or axillary incisions may require re-excision and closure of the incision.

Asymmetry

Asymmetry of the implant position may result from shifting of the implant, increased contraction of the capsule unilaterally, or ptosis of the implant, which is attributed to placement of steroids in the pocket and/or breast prosthesis.

Contour irregularity and implant extrusion

Contour irregularity and implant extrusion also are rare events that may be associated with the placement of implants. The most common cause of contour irregularity is a tight capsular contracture that may develop around the implant. A wide range of incidence of capsular contracture, from 0-74% of patients, has been noted following breast implantation. The incidence of capsular contracture appears to be approximately 30% of individuals who have undergone the procedure. Classification of the contracture is highly subjective. In 1980, Little and Baker developed a classification for the capsular contracture present in patients following breast augmentation, which remains the standard for evaluating this complication in patients. The grades of capsular contracture are divided into 4 types:

Grade I: Capsular contracture of the augmented breast feels as soft as an unoperated breast.

Grade II: Capsular contracture is minimal. The breast is less soft than an unoperated breast. The implant can be palpated but is not visible.

Grade III: Capsular contracture is moderate. The breast is firmer. The implant can be palpated easily and may be distorted or visible.

Grade IV: Capsular contracture is severe. The breast is hard, tender, and painful with significant distortion present. The capsule thickness is not directly proportional to palpable firmness, although some relationship may exist.

Subclinical infection may cause capsular contracture, with S epidermidis the most probable etiologic agent. Various techniques, including massage, which expands the size of the capsule, attempt to reduce the incidence of this complication. The role of antibiotics in the prevention of capsular contracture is unclear. Antibiotics may benefit if subclinical infection is a factor. However, in patients in whom this is not a problem, antibiotics provide no benefit to the individual. Capsule formation may require surgical capsulotomy, which involves circumferential and radial division of the capsule. In addition, the extent of the pocket is increased. Recurrence following capsulotomy approaches 30%. Complications of capsulotomy include bleeding, infection, and implant exposure.

Medicolegal pitfalls

Medicolegal pitfalls typically are concerned with informed consent. Discuss previously enumerated complications preoperatively. Recently, the Food and Drug Administration approved saline implants, but not for use in minors or via a periumbilical approach.

OUTCOME AND PROGNOSIS

Despite the extensive list of potential complications, breast augmentation remains one of the safest and most predictable procedures performed. The low incidence of complications and the predictability of surgical outcome have prompted an increasing number of individuals, who currently are dissatisfied with their breasts, to undergo the procedure. The surgery provides a balance between the size and shape of the individual's breast and overall body size and shape.

IMAGES

Caption: Picture 1. (Above) Preoperative view of 28-year-old woman with micromastia. She has had 2 children. Note the small breast has decreased upper pole fullness. (Below) Postoperative view after submuscular augmentation with a round implant. Notice increased fullness of the upper poles of the breasts. Submuscular placement makes it difficult to appreciate the edge of the implant.

Picture Type: Photo

Caption: Picture 2. (Above) Preoperative view of 26-year-old woman with minimal upper pole fullness and asymmetric breasts. (Below) Postoperative result after submuscular placement of anatomically shaped implants. Notice increased lower pole fullness and absence of upper pole fullness relative to the round implant shown in Image 1.

Picture Type: Photo

Caption: Picture 3. (Above) A 24-year-old woman with an A-cup breast. (Below) Postoperative result after subglandular placement with 460-cc implants. Note the lower position of the implant when placed subglandularly.

Picture Type: Photo

Caption: Picture 4. (Above) Preoperative view of a 27-year-old patient desiring augmentation. (Below) Postoperative view after augmentation with a round implant. Notice the smooth contour in the upper pole. The end of the implant is not perceptible because of submuscular placement.

Picture Type: Photo

Caption: Picture 5. (Above) Preoperative view of 23-year-old patient with micromastia. (Below) Postoperative view after augmentation with detachment of the inferior half of the pectoralis musculature from the sternal attachments to provide cleavage. Note increased medial projection.

Breast Augmentation, Endoscopic Assisted

INTRODUCTION

The trend in plastic surgery to minimize scarring by remote placement of access incisions is embodied in the transaxillary endoscopic augmentation mammoplasty. The incision is hidden within the axilla, in the first axillary crease, and is generally invisible even with the arm raised. The surgical control gained with the use of the endoscope has resulted in more consistent results, which has renewed enthusiasm for the axillary approach.

History of the Procedure: The transaxillary approach to breast augmentation was described by Troques in 1972 and Hoehler in 1973. Besides the obvious advantage of the hidden incision, direct access to the subpectoral plane is facilitated. The technique altered the inframammary crease and dissected the origin of the pectoralis muscle blindly, accounting for a significant incidence of implant malposition. The limited exposure of the blind technique did not allow complete division of the prepectoral fascia, resulting in the tendency of high-riding implants or the double bubble appearance of th