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Table of Contents:
1. Introduction to Breast Augmentation
2. Implant and Augmentation Information
3. Surgical Treatments
4. Complications
5. Outcome and Prognosis
6. References


Introduction to Breast Augmentation
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 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 cancer.1,2

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 percent.

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

Surgical Treatment  
Implant Placement

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.

Incisions

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

Subglandular

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

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.

Complications
Hematoma

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

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.

Sensory Changes

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.

Scars

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

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.

Contour 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 overall body. 

REFERENCES

1. Courtiss EH, Webster RC, and White MF: Selection of alternatives in augmentation mammoplasty. Plast Reconstr Surg 54:552,1974.

2. deCholnoky T: Augmentation mammoplasty: Survey of complications in 10,941 patients by 265 surgeons. Plast Reconstr Surg 45:573, 1970.

3. Cronin T and Gerow F: Augmentation mammoplasty: A new "natural feel" prosthesis. In Broadbent TR (Ed.): Transactions of the Third International Congress of Plastic Surgery. Amsterdam, Excerpta Medica Foundation, 1964.

4. Cronin TD and Greenberg RL: Our experiences with the Silastic gel breast prosthesis. Plast Reconstr Surg 46:1, 1970.

5. Ellenberg AH and Braun H: A 3-1/2 year experience with double-lumen implants in breast surgery. Plast Reconstr Surg 65:307, 1981.

6. Goldwyn R: Plastic and Reconstructive Surgery of the Breast. Boston, Little, Brown and Company, 1976.

7. Asplund O: Capsular contracture in silicone gel and saline-filled breast implants after reconstruction. Plast Reconstr Surg 73:270, 1984.

8. Baker JL, Jr, Bartels RJ, and Douglas WM: Closed compression technique for rupturing a contracted capsule around a breast implant. Plast Reconstr Surg 58:137, 1976.

9. Lilla JA and Vistnes LM: Long-term study of reactions to various silicone breast implants in rabbits. Plast Reconstr Surg 57:637, 1976.

10. Letterman G and Schurter M: History of augmentation mammoplasty. In Owsley JQ and Peterson RA (Eds.): Symposium on Aesthetic Surgery of the Breast. St. Louis, C.V. Mosby Company, 1978, pp. 243-249.

11. Rees TD, Guy CL, and Coburn RJ: The use of inflatable breast implants. Plast Reconstr Surg 52:609, 1973.

12. Ashley FL: Further studies on the Natural-Y breast prosthesis. Plastic Reconstr Surg 49:421, 1970.

13. McKinney P and Gilbert T: Long-term comparison of patients with gel and saline mammary implants. Plast Reconstr Surg 72:27, 1983.

14. Slade CL an Peterson HD: Disappearance of the polyurethane cover of the Ashley Natural-Y prosthesis. Plast Reconstr Surg 70:379, 1982.

15. Oneal RM and Argenta LC: Late side effects related to inflatable breast prostheses containing soluble steroids. Plast Reconstr Surg 69:641, 1982.

16. Jones FR and Tauras AP: A periareolar incision for augmentation mammaplasty. Plast Reconstr Surg 51:641, 1973.

17. Mahler D, Ben-Yakar J, and Hauben DJ: The retropectoral route for breast augmentation. Aesth Plast Surg 6:237, 1982.

18. Tebbetts JB: Transaxillary subpectoral augmentation mammaplasty: Long-term follow-up and refinements. Plast Reconstr Surg 74:636, 1984.

19. Woods JE, Irons GB, Jr., and Arnold PG: The case for submuscular implantation of prostheses in reconstructive breast surgery. Ann Plast Surg 4:2, 1980.

20. Maxwell GP: Discussion of "transaxillary subpectoral augmentation mammaplasty: Long-term follow-up and refinements." Plast Reconstr Surg 74:648, 1984.

21. Courtiss, EH, Goldwyn RM, and Anastasi GW: The fate of breast implants with infections around them. Plast Reconstr Surg 63:812, 1979.

22. Farina MA, Newby BG, and Alani HM: Innervation of the nipple-areola complex. Plast Reconstr Surg 66:497, 1980.

 
 

Copyright © 1999-2012 Jay M. Pensler, M.D.