Table of Contents:
to Breast Augmentation
2. Implant and Augmentation Information
3. Surgical Treatments
5. Outcome and Prognosis
to Breast Augmentation
Breast surgery is performed to enhance the size and
shape of a woman's breasts. Surgery typically improves the individual's
Historically breast enlargement has been accomplished by one of
three methods with varying results of success.
Inert material, such as silicone and paraffin, has been injected
directly into the parenchymal tissue to effect an increased size
of the breast. This method has been abandoned because of the exceedingly
high incidence of both acute and long-term complications. Granulomas
are frequent, as are complications of skin loss and scar contracture
producing excessive disfigurement.
Autogenous tissue injections have also been utilized in an attempt
to enhance and enlarge the shape of a woman's breasts. Autogenous
tissues, including omentum, fat, muscle, lipomas, skin in the
form of dermis and dermal fat grafts, have all been utilized to
enhance and enlarge the breasts. The results from injection of
autogenous tissue have not been positive. The results have been
unpredictable. In addition to the scarring and uneven texture
which may be visible in patients who have had injection of tissue
into the breasts, microcalcifications develop which make it impossible
to follow these women with mammograms for early diagnosis of breast
Recently a suction pump device has been utilized to try and enhance
the shape of women's breasts. However, while some enlargement
in patients have been noted, the overall shape in these individuals
has been significantly lacking.
Implants have been utilized since the 1960's to enhance and enlarge
the shape of female breast tissue and to this day remain the preferred
approach for augmentation mammaplasty. Silicone has been utilized
since 1964 when first reported by Cronin and Gerow and is utilized
for augmentation of female breasts today under investigational
approval.3 Advantages of silicone-filled implants include minimum
solubility of the silicone, excellent viscosity of the material
providing an excellent feel to the breasts. Problems associated
with silicone implants include capsular contracture, granulomas
which have developed following leaching of silicone from the implant,
and migration of the silicone into the axilla. Autoimmune responses
have been reported regarding silicone implants in breast augmentation.1-9
The reports regarding autoimmune phenomena in individuals with
silicone implants have been discredited due to a number of exhaustive
long-term studies which have failed to demonstrate increased incidence
of any long-term problem in large numbers of women who underwent
augmentation with silicone implants.
With the Food and Drug Administration's decision to temporarily
remove silicone implants due to purported increased incidence
of autoimmune phenomena which was later shown to not occur, a
considerable amount of interest arose regarding the use of saline
implants to augment breast tissue. Saline-filled implants have
been utilized since the 1960's. Saline is safely absorbed into
the blood stream if a loss in the integrity of the capsule of
the implant develops. In fact, saline is a solution that is commonly
used in intravenous solutions and poses no risk to individuals.
Saline implants are purported to have a decreased capsular contracture
rate when compared with silicone implants. Saline, however, has
slightly decreased viscosity compared to silicone. The initial
use of saline implants resulted in a high incidence of deflation,
in the range of ten percent. Over the last ten years significant
work by implant manufacturers to improve the integrity of the
implants and specifically improve the reliability of the valvular
mechanism for introduction of saline into the implant have resulted
in deflation rates which are predicted to be in the range of three
Implant and Augmentation Information
Implants may be of two shapes, round implants or tear-drop implants.
The round implants are disc shaped and exhibit equal fullness
in all four quadrants of the breast. Tear-drop or anatomic implants
exhibit reduced augmentation fullness in the upper pole of the
breast with increased fullness in the lower half of the breast.
These implants are also narrower at the superior and inferior
pole than the rounded implants. The implant surface may be smooth
or textured. Textured implants were initially developed in response
to the use of polyurethane covered silicone gel implants which
were first introduced in the early 1970's. Initial reports regarding
polyurethane covered silicone gel implants resulted in decreased
capsule formation.10 It was postulated that the ingrowth of scar
tissue into the polyurethane surface broke up the vector forces
of scar contracture. Because of the altered vectors of scar contracture
the capsule of the scar was not able to contract to the same degree
as was typically present around a silicone implant. This theory,
however, was never definitively proven in a scientific study.
It became clear, however, that polyurethane underwent microfragmentation
and phagocytosis.11,12 In addition, the possibility existed that
the polyurethane would be broken down and dissolved within the
tissue locally after placement of these implants.13 There was
an intense foreign body reaction with numerous macrophages and
multi-nucleated giant cells that occurred in the capsule surrounding
some patients who had implantation of this type of implant. Because
of these problems the 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 in a manner that would duplicate the effect noted
with polyurethane. This same approach was also attempted in saline
implants. Unfortunately the results from increasing the capsular
thickness with texturing of the surface has not provided conclusive
improvement in the rates of decrease of capsular contractures
in patients undergoing breast augmentation, while reports of increased
wrinkling have been noted due to placement of the textured implants
in individuals undergoing breast augmentation.10-16
The implants may be placed by one of a number of routes that typically
varies with surgeon preference and experience. The results that
the individual desires may also often influence the site for placement
of the implants.
An inframammary incision is the most common approach for placement
of a breast implant. This approach which entails a 3-4 cm incision
is attempted to be placed in or adjacent to the inframammary crease.
The inframammary approach provides the most direct route for placement
of the implant. In general, this approach requires the least operative
time for placement. Problems associated with inframammary incisions
include a scar that is visible on the anterior surface of the
breast. Additional problems center around the difficulty to place
the incision in the inframammary crease which is potentially exacerbated
with the low profile implants.9,10,15
Implants placed by an incision within the pigmented areolar tissue,
which is referred to as a periareolar incision, often result in
the least conspicuous scar.16
Dissection of the pocket required for placement of the implant
is, however, 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 have been associated with
microcalcification and cyst formation. Medial placement of the
periareolar implant incision within the areolar avoids the course
of the fourth intercostal nerve which supplies sensation to the
nipple and areola.16Incisions in the axilla, referred to as a
transaxillary approach, avoids placement of the scar on the breast.17,18 The transaxillary approach provides the least visible scarring.
Submuscular & Subglandular Implant Placement
The implants may be placed directly beneath the mammary gland
or in a plane below the pectoralis major muscle.10,19,20 The advantages
attributed to placement below the gland include ease of dissection,
predictable sizing and contouring, and satisfactory results provided
a capsular contracture does not occur. It is also feasible to
place larger size implants in a subglandular position than would
be possible in a submuscular placement. (Fig. 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.
(Fig. 4) Additional benefits which have been attributed to submuscular
placement include reduced sensory changes in the nipple and decreased
rates of capsular contracture and ease of interpretation of mammographic
studies.11 The submuscular plane is relatively avascular and the
dissection is straightforward. Disadvantages include limitations
on the size of the implant that may be placed, increased postoperative
pain, and the possibility towards lateral displacement of the
implant. In addition, it is more difficult to obtain significant
cleavage with the submuscular placement. If significant cleavage
is desired, detachment of the inferior portion of the pectoralis
musculature from its sternal attachments is required. (Fig. 5)
This results in increased discomfort for the patient postoperatively
and requires control of internal mammary arterial perforators.
The frequency of hematomas is reported to be less than two percent.
The associated symptoms of hematoma are typically unilateral pain,
swelling and occasionally fever. Hematomas may develop slowly
without symptoms or rapidly with symptoms. Small hematomas may
resolve on their own. Large hematomas require drainage. It is
preferable to delay drainage often until liquefication of the
clot has occurred. However if the hematoma is painful or large,
drainage should be carried out immediately.6,7,13
Infection has been purported to be approximately two percent.
Infection becomes apparent seven to ten days postoperatively but
may manifest itself at any point in time. Presenting symptoms
for infection include swelling, discomfort, pain, drainage and
cellulitis overlying the breast. The wound, once an infection
is identified, should be drained and irrigated. Removal of the
implant may not always be necessary, particularly if a periareolar
incision was used with the initial surgery.21 Antibiotics are
prescribed immediately. Infection, if the implant was not removed,
may result in severe capsular contracture. If the implant is removed
following infection, may be replaced in three to six months. Infections
may be commonly caused by Staph epidermidis or Staph aureus.
Changes in nipple-areolar sensation are common postoperatively
in patients who have undergone breast augmentation. The majority
of patients exhibit a temporary dysesthesia. This tends to resolve
in a period of months.22 A small percentage of individuals, however,
may present with long-term sensory changes in one or both nipples
following breast augmentation. The increased incidence of sensory
changes is noted with transaxillary augmentation as this approach
directly crosses the fourth intercostal nerve which supplies sensation
to the nipple-areolar area.
Hypertrophic or keloid scar formation is uncommon following breast
augmentation. The lowest incidence of hypertrophic scarring appears
to be observed in periareolar incisions. The presence of a hypertrophic
scar in the inframammary or axillary incisions may require re-excision
and closure of the incision.
Asymmetry of the implant position may result. This may be due
to shifting of the implant, increased contraction of the capsule
unilaterally, or ptosis of the implant which has been attributed
to the use of steroids placed in the pocket and or breast prosthesis.
Irregularity and Implant Extrusion
Contour irregularity and implant extrusion are also rare events
that may be associated with placement of implants. The most common
cause of contour irregularity is a tight capsular contracture
which may develop around the implant. A wide range of the incidence
of capsular contracture ranging between 0-74% of patients has
been noted following breast implantation. The most common numbers
utilized for the incidence of capsular contracture center around
thirty percent of the individuals who have had the procedure.
Classification of the contracture is highly subjective. Little
and Baker in 1980 developed a classification for the capsular
contracture present following patients with breast augmentation,
and this still utilizes the standard for evaluation of this complication
in patients.13 The grades of capsular contracture are divided
into four types: 1) Grade I classification of capsular contracture
of the augmented breast feels as soft as an unoperated breast.
2) Grade II capsular contracture is minimal contracture. The breast
is less soft than an unoperated breast. The implant can be palpated
but is not visible. 3) Grade III is moderate. The breast is firmer.
The implant can be palpated easily. It may be distorted or visible.
4) Grade IV is severe. The breast is hard, tender, painful with
significant distortion present. The thickness of the capsule is
not directly proportional to palpable firmness, although some
relationship may exist. Subclinical infection has been proposed
to cause capsular contracture, the most probable etiologic agent
being Staphylococcus epidermidis. Various techniques including
massage which expands the size of the size of the capsule have
attempted to reduce the incidence of this complication. The role
of antibiotics is unclear in the prevention of capsular contracture.
Antibiotics may be beneficial if subclinical infection proves
to be a factor. However in cases where 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
thirty percent. Complications of capsulotomy include bleeding,
infection, and implant exposure.7
Outcome and Prognosis
In spite of the extensive lists of potential complications,
breast augmentation remains one of the safest and most predictable
procedures performed today. The low incidence of complications
and the surgical predictability of results has resulted in an
increased number of individuals who note dissatisfaction related
to their breasts to undergo the procedure. The procedure provides
a balance between the individual's breast size and shape and their
Courtiss EH, Webster RC, and White MF: Selection of alternatives
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