- 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.
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Implant
and Augmentation Information back
to top
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
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Surgical Treatment
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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 clude 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.16
Axillary incisions are hidden in creases in the armpit. This approach requires special instrumentation and expertise. The incisions are the least noticeable and complication rates for this approach are reduced as well.
A
periumbilical approach, placement through the umbilicus, has
been utilized for augmentation of the female breast. This approach
is restricted by placement of the implant in a pre-pectoral
plane and provides the worst control for dissection of the pockets,
making superior dissection and symmetry of placement difficult,
even in the most experienced hands. Complications of hematoma
or infection require a conversion to one of the other incisions
for removal of the implant. In addition, a special type of valvular
mechanism is required for placement of saline-filled implants
through a periumbilical approach, and the long-term reliability
of the valvular mechanism in these implants has not been fully
clarified at this point in time to the author's satisfaction.
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
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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
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Outcome and Prognosis
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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
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to top
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.
