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4 The Science ofChoosing aBreast Implant
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Fig. 4.8 Measuring the pinch thickness of the breast upper pole using a calipers
41
To measure anterior pull skin stretch, grasp the areolar
skin medially and stretch it maximally anteriorly. Holding
the ngernail at the anterior location, release the skin and
caliper measure from the ngernail back to the skin of
unstretched areola (Fig.4.7).
To measure the soft tissue pinch thickness of the upper
pole, isolating the breast parenchyma inferiorly, pinch rmly
and caliper measure the thickness of skin and subcutaneous
tissue superior to breast parenchyma (Fig. 4.8). Similarly,
pinch rmly to measure soft tissue pinch thickness at the
inframammary fold.
Measure the preoperative nipple-to-inframammary fold
distance under maximal stretch by placing a dot at existing
inframammary fold and at the middle of the nipple on its
medial border. Place the tip of exible tape measure exactly
on nipple dot, lift, stretch the lower pole skin maximally
upwards, and measure to the dot at the inframammary fold
(Tebbetts 2002) (Fig.4.9).
Fig. 4.9 Measuring the nipple-to-inframammary fold distance at maximum stretch
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A. Dhir and N. Bansal
.
.
.
.
.
.
.
.
parenchyma's contribuon to stretched envelope ll
11
5
4
55
66
3
22
4
1. Base width (BW)
2. Nipple to inframammary fold distance (N-IMF)
3. Intermammary distance
4. Stemal notch to nipple distance (SN-N)
5. Soft tissue pinch test (PT)
6. Maximum skin stretch (MSS)
Fig. 4.10 A summary of the various measurements required to choose the ideal breast implant
insertion
insertion
insertion
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43
4.7 Position ofBreast Implant
Three implant pocket locations are commonly used in augmentation mammaplasty (Fig.4.11):
1. partially behind the pectoralis major muscle (partial retropectoral) (Dual plane)
2. behind breast tissue and mammary gland (subglandular),
3. totally behind pectoralis major and serratus (total
submuscular).
Each of the listed implant pocket locations has specic
benets and indications, but each also has unique tradeoffs in
specic breast types. When a surgeon uses only one pocket
location for all primary breast augmentations, it is logical that
compromises, complications, or less than optimal results will
occur, because a single pocket location does not completely
address the range of anatomic variations and implant- soft tissue dynamics that occur in a wide range of breast types.
Despite the benet of the subglandular position, placement of the implant behind the gland may result in an unfavorable outcome in terms of implant edge visibility. This is
more evident in thin patients with less soft tissue coverage, in
whom a sharp transition can be seen in the upper pole. The
submuscular position was introduced to provide optimal
implant coverage. However, the main drawbacks with this
approach are related to implant distortion, breast asymmetry,
and postoperative pain (Tebbetts 1984).
To address this issue Tebbetts (1984, 2001, 2002) suggested dual plane augmentation, which is dened as any augmentation that meets the following three criteria:
• The implant lies partially behind the pectoralis major
muscle and partially behind the breast parenchyma (in
dual planes simultaneously).
• A specic group of pectoralis major muscle origins are
totally divided in a specic area to alter implant-soft tissue dynamics by anatomically repositioning portions of
the pectoralis major relative to the implant (this criterion
distinguishes dual plane from partial retropectoral
augmentation).
• The parenchyma-muscle interface is specically altered
to change the soft tissue relationships between pectoralis
major and parenchyma and to change the implant parenchyma dynamics.
In dual plane augmentation, the surgeon alters the posi-
tion of portion of the pectoralis major muscle by (a) selectively dividing the inferior origins of the pectoralis along the
inframammary fold only, with no muscle division along the
sternum; and (b) freeing the attachments of parenchyma to
muscle at the parenchyma-muscle interface by dissecting in
the retromammary plane between the parenchyma and the
pectoralis (Fig.4.12). These two maneuvers are performed at
different times and to different degrees, depending on incisional approach, breast type, tissue characteristics, implantsoft tissue dynamics, and the surgeon’s preferences (Tebbetts
2001).
4.7.1 BIA-ALCL
Breast Implant-Associated Anaplastic Large Cell Lymphoma
(BIA-ALCL) is an uncommon T-cell lymphoma, CD30−
positive, ALK-negative, that typically presents itself as a
spontaneous periprosthetic uid collection or a capsular
mass on the implant (Clemens and Horwitz 2017). BIAALCL occurs most frequently in patients who have breast
implants with textured surfaces. This is a cancer of the
immune system, not a type of breast cancer. Several risk fac-
Fig. 4.11 Schematic diagram
showing the position of the
implant in relation to the
pectoralis major muscle
Dual-Plane
Breast
inplant
Subglandular
Breast
inplant
Breast
inplant
Submuscular
44
ymphoma Cells
Breast Cancer BIA-ALCL
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A. Dhir and N. Bansal
tors are suggested, but a clear understanding of the underlying causes remains unclear. The presence of a subclinical
biolm on the implant surface, capsular contracture,
repeated capsular trauma, genetic predisposition, or an autoimmune etiology have been theorized. A direct/indirect
immunologic response, direct toxic damage from the silicone components, or both have also been hypothesized (Ye
etal. 2014).
BI-ALCL appears to have two distinctively different
pathologic entities. The more common is in situ disease,
which is conned within the seroma, i.e., periprosthetic effusion around the breast implant, or on the inner layer of the
capsule surrounding the implant. In situ disease does not
manifest as a palpable breast mass or tumor, and is often
misinterpreted as a benign seroma due to subclinical infec-
Fig. 4.12 Position of the implants as in relation to the pectoral muscle.
The pectoral bers arising from the costal heads have to be divided
keeping the sternal origin intact in a subpectoral breast implant
placement
tion. A smaller portion of patients present with an inltrative
disease course, with a tumor growing through the capsule or
outside of it, forming a palpable breast mass with or without
periprosthetic effusion. BI-ALCL with lymph node involvement and no breast mass has also been described (Tardío and
Granados 2015) (Fig.4.13).
Common symptoms include breast enlargement, pain,
asymmetry, lump in the breast or armpit, overlying skin rash,
hardening of the breast, or a large uid collection typically
developing at least more than 1 year after receiving an
implant, and on average after 8–10 years.
BIA-ALCL has been found with both silicone and saline
implants and both breast cancer reconstruction and cosmetic
patients. To date, there are not any conrmed BIA-ALCL
cases that involve only a smooth implant. This is the reason
smooth implants with cohesive gel are preferred by
surgeons.
4.7.1.1 Diagnosis
The National Comprehensive Cancer Network (NCCN)
established guidelines for the diagnosis and treatment of
this disease in 2016 and updated in 2019 (Elswick and
Nguyen 2018). Because the most common form of clinical
presentation is a seroma, ne-needle aspiration (FNA) and
cytologic evaluation and ow cytometry of uid collected
is recommended. In a minority of cases that do not present
any uid, ultrasound-guided, or open biopsy may be necessary to collect samples of capsular mass, abnormal skin, or
enlarged and suspicious lymph nodes. Cytopathologic
diagnosis of BIA-ALCL is based on the presence of large
cell, atypical, pleomorphic, and anaplastic morphology
with eosinophilic cytoplasm. Immunohistochemistry will
show large sheets of tumor cells expressing CD30, and a
single T-cell clone is evident on ow cytometry. BIAALCL does not express the anaplastic lymphoma kinase
Fig. 4.13 Difference
between Breast cancer and
BIA-ALCL.As seen in the
illustration, the ALCL and the
Lymphoma cells are limited
and restricted within the
capsule of the implant
Breast tissue
Breast Cancer
Breast Implant
Breast tissue
Effusion Fluid
L
Fibrous Capsule
t
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Fig. 4.14 An en-bloc implant
removal along with
capsulectomy in progress.
The plane of dissection is
shown in a submuscular
implant placement. Same
technique is used in the
subglandular implant too.
This is the treatment of choice
for majority of cases
45
Pectoralis major m.
Breast parenchyma
Lighted retractor
Textured implan
Scar capsule
Effusion
IMF
Mass
-Plane of dissection
translocation (i.e., it is ALK- negative), which is critical to
differentiate from systemic ALK-positive ALCL
(Magnusson etal. 2019).
4.7.1.2 Treatment
Surgical treatment consists of the removal of the implant,
total capsulectomy and for advanced stages (II, III, or IV),
lymphadenectomy, in which case the patient should be
referred to a surgical oncologist. Sentinel-node biopsy
appears to not be applicable in the treatment of BIA-ALCL
(U.S. Food and Drug Administration (FDA) 2019). After
capsulectomy and implant removal, breast reconstruction
should be performed with autologous tissue (Clemens etal.
2019) or smooth implants. NCCN advises removing both
implants due to some cases of incidental ndings in the contralateral breast. The majority of patients do not require further treatment besides implant removal and total capsulectomy
(stage I) (Fig.4.14). Further treatment may be necessary for
advanced stages (II to IV), but there is no standardized therapy so far due to the small number of cases worldwide.
NCCN guidelines were updated in 2019 (Elswick and
Nguyen 2018) with the recommendation of adjuvant therapy
with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). However, frontline therapy with brentuximab vedotin, an antibody–drug conjugated to a chimeric
CD30, has been reported to produce good results, and it is
now considered the “preferred” rst line therapy (RamosGallardo etal. 2018; Nava etal. 2018). Residual or unresectable disease may eventually require radiotherapy.
Surveillance after implant removal and capsulectomy should
involve examinations every 3–6 months, CT of chest, abdomen, and pelvis, or PET/CT scans every 6 months for the
rst 2 years after the surgery.
4.7.1.3 Survival andMortality
The majority of patients diagnosed with BIA-ALCL can be
cured. Complete capsular removal is the most important factor in survival and cure; thus, preoperative planning is mandatory, and the lack of adequate treatment may allow disease
progression. The presence of tumor nodules, axillary lymph
node involvement, bilateral breast involvement, and inltrative pattern on capsule histology are correlated with more
aggressive behavior. Clemens et al 2019 and Alderuccio
et al. 2018 reported the outcomes after treatment of BIAALCL. Both the presence of a mass and the extracapsular
disease were associated with increased risks of recurrence
and death.
4.8 Three-Dimensional Imaging
forBreast Augmentation
The rst two dimensions of the breast consist of the breast
footprint and the third dimension consists of the breast shape.
The breast footprint has an upper breast border, an inferior breast border (inframammary fold), a medial breast border, and a lateral breast border. Understanding the anatomy
and parameters of these borders is key to understanding what
can be changed. The base of the footprint and how steep the
angle of the chest wall is as it slopes away from the chest
wall are important for the surgeon to visualize. The breast is
a mobile skin structure that is held in place by zones of
adherence. The inframammary fold is a relatively xed
structure, and the skin over the sternum is also xed. When a
patient lies on her side, the upper breast folds over at the
medial breast border and the lower breast slides out laterally.
The upper breast border is mobile but the lower breast border
46
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A. Dhir and N. Bansal
Fig. 4.15 ‘CRISALIXR’ software being used to assess placement of breast implant as well as a breast lift
is adherent at the inframammary fold. The third dimension is
the breast shape. The actual shape of the breast and how it
sits on that footprint are very important. Breast width, upper
tion preoperatively with patients who desire a higher-thanoptimal ll volume and are relying on the simulations to
choose a particular size (Roostaeian and Adams Jr. 2014).
and lower pole fullness, and ptosis all need to be assessed.
Finally, the position of the nipple on the breast mound gives
the nal esthetic result.
References
Several software are available (like CRISALIXR) (Fig.4.15)
that help the patient to visualize postsurgery images according
to the implant size being used. These are easy to use software
that only require preoperative photographs of the patient and
create the postoperative image from the same.
However, the system is not particularly accurate when the
simulated image is compared to the actual postoperative
image. This adds additional time during the consultation to
reassure patients that the simulated image is not accurate.
Additional time is also needed to manually adjust the image
to achieve a more realistic outcome. Better simulations can
be achieved when the default landmarks are adjusted—and
this takes time. Furthermore, when greater ll volumes are
chosen, the extra volume becomes apparent in the upper pole
of the breast; however, the default simulation software is set
up to demonstrate an optimally lled breast and is not able to
demonstrate this increase in upper-pole fullness without
manual manipulation. It is important to discuss this limita-
Alderuccio JP, Desai A, Yepes MM, etal. Frontline brentuximab vedo-
tin in breast implant-associated anaplastic large-cell lymphoma.
Clin Case Rep. 2018;6:634–7.
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Arion HG. Retromammary prosthesis. C. R. Soc Fr Gyneco; 1965;p.5.
Clemens MW, Horwitz SM.NCCN consensus guidelines for the diag-
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Cronin TD, Gerow FJ.Augmentation mammaplasty: a new “natural
feel” prosthesis. Excerpta Med Int Congr Ser. 1963;66:41.
Eisenberg TS.Silicone gel implants are back— so what? Am J Cosmet
Surg. 2009;26:5–7.
Elswick SM, Nguyen MT.Breast erythema in a patient with breast
implant associated anaplastic large cell lymphoma: a case
report discussing cutaneous manifestations. Aesthet Surg J.
2018;38:NP47–52.
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Luu HM, Hutter JC, Bushar HF. A physiologically based pharma-
cokinetic model for 2,4-toluenediamine leached from polyurethane foam-covered breast implants. Environ Health Perspect.
1998;106(7):393–400.
Magnusson M, Beath K, Cooter R, etal. The epidemiology of breast
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implants. Plast Reconstr Surg. 2019;143:1285–92.
Nava MB, Adams WP Jr, Botti G, etal. MBN 2016 aesthetic breast
meeting BIA-ALCL consensus conference report. Plast Reconstr
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Nichter LS, Hardesty RA, Anigian GM. Ideal implant structured
breast implants: core study results at 6 years. Plast Reconstr Surg.
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Ramos-Gallardo G, Cuenca-Pardo J, Cardenas-Camarena L, et al. Is
Latin America ready to identify anaplastic large cell lymphoma in
breast implants patients? Regional encounter during the national
plastic surgery meeting in Cancun, Mexico. Aesthetic Plast Surg.
2018;42:1421–8.
Roostaeian J, Adams WP Jr. Three-dimensional imaging for breast
augmentation: is this technology providing accurate simulations?
Aesthet Surg J. 2014;34(6):857–75.
Tardío JC, Granados R.Axillary lymphadenopathy: an outstanding pre-
sentation for breast implant– associated ALK-negative anaplastic
large cell lymphoma. Int J Surg Pathol. 2015;23(5):424–8.
Tebbetts JB. Transaxillary subpectoral augmentation mamma-
plasty: long-term follow-up and renements. Plast Reconstr Surg.
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Tebbetts JB.Dual plane breast augmentation: optimizing implany-soft
tissue relationships in a wide range of breast types. Plast Reconstr
Surg. 2001;107:1255.
Tebbetts JB.Breast implant selection based on patient tissue charac-
teristics and dynamics: the TEPID approach. Plast Reconstr Surg.
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ciated anaplastic large cell lymphoma (BIA-ALCL). www.fda.gov/
medicaldevices/productsandmedicalprocedures/implantsandpros-
thetics/breastimplants/ucm239995.htm. Accessed 5 Aug 2019.
Ye X, Shokrollahi K, Rozen WM, Conyers R, Wright P, Kenner
L, et al. Anaplastic large cell lymphoma (ALCL) and breast
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Zannis J.Tales for Tagliacozzi: an inside look at modern–day plastic
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Periareolar Breast Augmentation
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JosephJ.Castellano andBradleyC.Stephan
5
5.1 Introduction
The decision to pursue breast augmentation is a unique process for each interested patient, as each individual has their
own goals and desires. Esthetic surgeons see many patients
who have long been frustrated by a small breast size or asymmetric breasts; they often want to wear form-tting clothing
and feel more feminine, as well as condent.
Breast augmentation has been performed since the nineteenth century. One of the rst breast augmentation procedures
was performed by the Austrian surgeon Gersuny in 1899, by
injecting parafn directly into the breasts (Peters and Fornasier
2009). This procedure was wrought with complications and
was soon after abandoned. Afterwards, surgeons in the early
1900s attempted breast augmentation via fat transfer alone
(but met with marginal results at the time, likely due to primitive techniques for harvesting and handling of the adipose tissue); attempts to use sponges, polyurethane, cartilage, and
other substances were made during the following few decades
(Peters and Fornasier 2009). Patients have also used a variety
of lotions and vacuum suction devices over the years in an
attempt for breast enhancement. Most of these breast augmentation modalities, except for adipose transfer, have been abandoned due to poor and often dangerous results. This later gave
rise to a much safer manner to perform breast augmentation—
via silicone or saline-lled prosthetic implants.
Breast implants have been used since the 1960s to enhance
the size and shape of the female breast. The rst silicone implant
was created in the early 1960s and the rst saline implant in 1964
(Walden 2009; Ramachandran 2008). Both types of implants
have been modied signicantly since. Silicone implants were
initially used more often but their use was temporarily banned in
1992 due to concerns of silicone implant-associated autoim-
Supplementary Information The online version contains supplementary material available at
J. J. Castellano (*) · B. C. Stephan
Castellano Cosmetic Surgery Center, Tampa, FL, USA
https://doi.org/10.1007/978- 981- 99- 3726- 4_5.
mune disease and other health issues (Walden 2009). This ban
was reversed in 2006 as there had been no conclusive data to
support a link between silicone breast implants and systemic disease (Walden 2009). An association between textured breast
implants and lymphoma was later encountered. However, the
safety of smooth silicone and smooth saline implants has been
supported by numerous studies, employing many thousands of
patients, over approximately the last 15 years. Today’s breast
implants are available in a variety of sizes (base widths and projections) and shapes (i.e., round and teardrop).
There are four commonly utilized primary incision sites for
esthetic breast augmentation—periareolar, inframammary,
axillary, and umbilical. The two most common incisions are by
far the inframammary and periareolar incisions (Reece etal.
2009). Furthermore, there are multiple locations for breast
implant placement in relation to the pectoralis major muscle—
totally subpectoral (commonly referred to as subpectoral), subglandular (between the breast tissue and pectoralis major), and
dual-plane (with part of the implant within the subpectoral
location and the inferior aspect of the implant between the
breast tissue and underlying chest wall musculature).
In our practices, we commonly perform subpectoral or
dual-plane breast augmentation via a periareolar (PA) incision. Our experiences have demonstrated safe and esthetically excellent results when compared to other methods of
incision and implant placements. This chapter will describe
our technique, typical postoperative patient care, complications that have been encountered (and how to correct the complications), before and after pictures of patients who have
undergone periareolar breast augmentations under our care,
and general surgical tips to perform this procedure safely and
effectively. Of note, we almost exclusively use smooth, round
silicone-lled breast implants due to the exceptional esthetic
results, the relative lack of postoperative rippling, patient
preference, and the lack of association with Anaplastic Large
Cell Lymphoma with these types of breast implants. Only the
use of smooth, round silicone breast implants will be discussed below; however, this technique may be easily modied for use with most other types of implants.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_5
49
50
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5.2 Evaluation andTechnique
The ideal candidate for a primary periareolar breast augmentation (PABA) is an individual with minimal to no comorbidities, does not use tobacco products, has Grade 1–2 ptosis,
has healthy skin and dermis with adequate elasticity, has
realistic expectations, and is emotionally sound. Another
important physical examination characteristic is the diameter
of the patient’s areolas. In our experience, patients’ areolas
need to have a preoperative diameter of approximately three
centimeters, on gentle spreading stretch, to proceed with
periareolar breast augmentation (Fig.5.1). A 3-cm diameter
of the areola will allow for the placement of up to approximately 560cc smooth round breast implants of intermediate
cohesivity. Moderately larger less cohesive implants and
moderately smaller more cohesive implants may be placed
utilizing this 3-cm measurement of the areola diameter.
Larger implants may be placed if the areola diameter is larger
than 3cm.
The planned periareolar incision site, midline, planned
superior extension of the implant pocket, inframammary
fold, as well as the inferior limit of where the implant should
rest are marked in the preoperative area with the patient
standing. (Fig.5.2) The periareolar incision markings extend
from the 3 o’clock to 9 o’clock positions along the inferior
aspect of the areola, where the areola meets the normal skin.
It is important to place the incision exactly where the areola
J. J. Castellano and B. C. Stephan
Fig. 5.1 Measurement of areolar diameter
Fig. 5.2 Preoperative
marking
Superior extension of Impl
pocket
Midline
Peri-areolar incision
Infra-mammary crease
Lower limit of implant pocket
dissection
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meets the normal skin for best postoperative wound healing.
Next, the breast is placed upon gentle upward vertical retraction and a tape measure is used to determine where the inferior aspect of the implant (and hence, the inferior limit of
dissection) should be placed. As a general rule, the center of
the implant (highest point of implant) should be in line with,
or slightly inferior to, the nipple. Where the inferior limit of
the implant is placed depends upon the base width of the
breast implant. If the breast implant has a base width of
14cm (for simplication purposes), the inferior mark should
be placed just more than 7-cm inferior to the nipple, again,
with the breast on gentle upward retraction. This will allow
the center of the implant to align with the nipple once postoperative settling of the implant has occurred. See Fig.5.2
for preoperative markings.
After preoperative markings are performed, the patient is
taken to the operating room, placed supine on the operating
table, and provided general anesthesia (without paralytics).
Arms are abducted to 90°, the arms are gently secured, and
the patient is prepped and draped, with care to not let the
adhesive of the drapes pull on and therefore distort the
breasts (Fig.5.3). Either betadine or chlorohexidine may be
used for painting of the area; however, we prefer chlorohexidine as there is less of a tendency to remove the preoperative
markings, and chlorohexidine has been shown to be a better
bacteriostatic agent. The surgery is started with the assistant
holding the skin with a gentle spreading tension over the
nipple areola complex (NAC) and the surgeon making a
sharp incision along the previously-marked areola-skin junction with a 15-blade scalpel down just through the dermis
from the 3 o’clock to 9 o’clock positions (Fig.5.4). Cautery
with a needle tip is used for hemostasis.
The dermis of the superior and inferior edges of the incision is grasped with small Allis clamps and retracted
anteriorly- superiorly and anteriorly-inferiorly, respectively.
The surgeon will then use blunt curved Metzenbaum scissors
to gently spread tissue apart in a transverse manner, approxi-
Fig. 5.3 Draping
51
Fig. 5.4 Initial periareolar (PA) incision
Fig. 5.5 The initial dissection by gently spreading action of the
scissors
mately 0.5–1.0 cm “deep” to the skin along the inferior
aspect of the breast, with the curve of the scissors following
the curve of the inferior aspect of the breast (Fig.5.5). This
allows for a small envelope of tissue to remain along the
inferior aspect of the breast between the nal implant and
skin while preserving the milk ducts. Cautery is used
sparingly. The Allis clamps are sequentially traded for the
short end and then the longer end of Army-Navy retractors as
the dissection proceeds. The use of Deaver retractors may be
necessary for individuals with larger breasts. Note that while
performing this dissection 0.5–1.0cm deep to the skin of the
inferior aspect of the breast, a small amount of true breast
tissue may be encountered. Therefore, it is important to use
blunt Metzenbaum scissors, a careful spreading action of the
scissors, and minimal cautery to preserve any encountered
milk ducts. The surgeon periodically digitally palpates
within the incision to ensure dissection is carried down
directly upon a rib (normally the fourth or fth rib), to ensure
the best dissection of the inframammary fold and to avoid
any risk of lung injury. Once the pectoralis major is encoun-
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