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Augmentation Mammaplasty
99. Friedman T, Davidovitch N, Scheflan M. Comparative
double blind clinical study on round versus shaped
cohesive gel implants . Aesthet Surg J. 2006;26:530 – 536.
1 0 0 . Baeke JL. Breast deformity caused by anatomi-
cal or teardrop implant rotation. Plast Rec
2002;109:2555 – 2564; discussion 2568.
1 0 1 . Schots JM, Fechner MR, Hoogbergen MM, van Tits HW.
Malrotation of the McGhan Style 510 prosthesis. Plast
Reconstr Surg. 2010;126:261 – 265.
1 0 2 . Mazzocchi M, Dessy LA, Corrias F, Scuderi N. A clinical
study of late seroma in br
Aesthetic Plast Surg. 2012;36:97 – 1 0 4 .
1 0 3 . Pinchuk V, Tymofii O. Seroma as a late complica-
tion after breast augmentation. Aesthetic Plast Surg.
2011;35:303 – 314.
1 0 4 . Jewell M, Spear SL, Largent J,
Jr. Anaplastic large T-cell lymphoma and breast
implants: A review of the literature. Plast Reconstr Surg.
2011;128:651 – 661.
1 0 5 . Kim B, Roth C, Chung KC, et al. Anaplastic large cell lym-
phoma and breast implants: A sy
Reconstr Surg. 2011;127:2141 – 2150.
east implantation surgery.
Oefelein MG, Adams WP
stematic review. Plast
onstr Surg.
1 0 6 . Kim B, Roth C, Young VL, et al. Anaplastic large cell
lymphoma and breast implants: Results from a structured expert consultation process. Plast Reconstr Surg.
2011;128:629 – 639.
1 0 7. Taylor K
large cell lymphoma and breast implants: Five
Australian cases. Plast Reconstr Surg. 2012;129:
610e – 617e.
1 0 8 . Eaves FF, Haeck PC, Rohrich RJ. Breast implants and ana-
plastic large cell lymphoma (ALCL): Using science
guide our patients and plastic surgeons worldwide. Plast
Reconstr Surg. 2011;127:2501 – 2503.
1 0 9 . Tebbetts JB. Achieving a predictable 24-hour return
to normal activities after breast augmentation: Part I.
Refining practices by using motion and time study principles. Plast Rec
291 – 292.
1 1 0 . Tebbetts JB. Achieving a predictable 24-hour return
to normal activities after breast augmentation: Part II.
Patient preparation, r
instrumentation. Plast Reconstr Surg. 2002;109:293 – 305;
discussion 306 – 307.
O, Webster HR, Prince HM. Anaplastic
to
onstr Surg. 2002;109:273 – 290; discussion
efined surgical techniques, and
14
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Breast Augmentation
Journal
ue
Vie
cle
View Article
CME
William P. Adams Jr., M.D.
Patrick Mallucci, M.D.
Dallas, Texas; and London,
United Kingdom
ME
earch
ind a Previous Iss
Learning Objectives: After reading this article, the participant should
be able to: 1. Cite the key concepts in the process of breast augmentation
that optimize outcomes; 2. Cite key components of tissue-based planning for
implant selection; 3. Discuss complications and risks of breast augmentation.
Summary: Breast augmentation remains one of the top surgical procedures performed by plastic surgeons. Current literature supports the concept
that breast augmentation outcomes are optimized using a concept of “the
process of breast augmentation.” Breast augmentation is often thought of as
a surgical procedure; however, the nonsurgical aspects of the procedure are
more important for optimizing outcomes and minimizing reoperation and
complications. The process of breast augmentation includes patient education, tissue-based preoperative planning, refined surgical technique, and
defined postoperative management. This CME article reviews and discusses
the current relevant topics and issues surrounding breast implants. There
are also supporting videos to enhance the reader’s experience. CME questions are present at the end for a self-assessment. (Plast. Reconstr. Surg. 130:
w Arti
reast augmentation is the most popular cosmetic
surgery procedure performed worldwide.
B
of the first implants in the early 1960s and has undergone continued refinement in patient management
techniques and implant technology.
back to the late 1800s. Vincenz Czerny, in 1895, used
a lipoma from a woman’s back to augment her breast.3
The early 1900s through the 1950s saw the development
of injectable substances ranging from glass, rubber,
Silastic, paran, liquid silicone to almost any material
imaginable, with disastrous results—many women
ended up with mastectomies to remove impregnated,
inflamed, painful beasts.
procedure has evolved greatly since the inception
The first attempts at augmentation of the breast date
4 – 8
598e, 2012.)
1,2
This
envelope filled with viscous liquid silicone and a Dacron
patch at the back to prevent rotation. These were known
as the first-generation implants. Subsequent development over the past 40 to 50 years has led to the development of fifth-generation implants, which are used
today (Table1).
TYPES OF BREAST IMPLANTS
Implant Filler
The two main types of breast implants in use today
are silicone or saline, both with outer silicone elastomer shells. Saline has been used predominantly in the
United States because of the silicone controversy of the
early 1990s and the moratorium on the use of silicone
implants between 1992 and 2006. In Europe and the
In 1961, Cronin and Gerow developed the first silicone prosthesis with the Dow Corning Corporation9
that consisted of a teardrop shape with a silicone rubber
From the University of Texas Southwestern Medical Center
and private practice, and the Royal Free and University College
Hospitals.
Received for publication November 23, 2011; accepted April 30,
2012.
Copyright ©2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318262f607
15
rest of the world, the vast majority of implants used have
been silicone, as they are generally regarded as superior
in terms of feel and durability. Changes in the gel fill of
Disclosure: Dr. Adams is an investigator for Allergan and
Mentor, a member of the Education Advisory Council for
Allergan, a royalty recipient for Atlas McGraw-Hill, and chief
medical officer of the Plastic Surgery Channel. Dr. Mallucci
lectures and teaches on behalf of Allergan, but has no financial or contractual relationship with them.
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Breast Augmentation
Table 1. Generations of Silicone Gel–Filled
Breast Implants
Implant
Generation
First 1960s Thick shell (0.25-mm
Second 1970s Thin shell (0.13-mm
Third 1980s Thick, silica-reinforced,
Fourth 1992–present Stricter manufacturing
Fifth 1993–present Cohesive silicone
Production
Period Characteristics
average); thick, viscous
gel; Dacron patch
average); less viscous
gel; no patch
barrier coat shells
standards; refined
third-generation devices
gel–filled devices;
form-stable devices
modern implants have led to the development of form-
the degree of science currently available, it would be difficult to conceive of what other evidence could be added
to answer this question in the eyes of some individuals.
Nevertheless, the silicone moratorium in the United
States prompted the widespread use of saline implants
not seen in other parts of the world where silicone had
not been banned. Saline has long been seen as second
choice to silicone because of problems with deflation
and underfilling and overfilling, giving rise to unnatural
feel and texture.
Other implant types emerged as alternatives to silicone as a result of the silicone scare. These include
Trilucent (soybean oil) implants, marketed as unique
because of their “natural” composition and radio-
19 – 22
graphic translucency.
These were withdrawn
because of elevated carcinogenic levels in the breakdown product of the soya. Hydrogel implants, also
stable gels that are highly cohesive through increased
cross-linking of silicone.
Silicone Gel Implant Moratorium in the United
States in 1992
In 1992, silicone implants were eectively removed
from use other than for reconstructive or revision purposes in a trial setting. The silicone controversy arose
as a series of high-profile media cases alluded to complications following breast augmentation with silicone
implants. The complications reported were largely
alleged systemic autoimmune diseases; however, extensive population studies worldwide since have failed to
prove any link between silicone implants and any autoimmune or other disease process. The silicone implants
were available for reconstruction and revision/replacement subsequently as multiple U.S. Food and Drug
came and went rapidly because of the inability to
demonstrate safety data.
23
MODERN IMPLANT CHARACTERISTICS
Modern Generation Silicone Implants
The main advances in implant technology have
consisted of changes to both the shell and the silicone
gel. The features of most modern shells lie in their
barrier layer technology and surface texturing options.
The barrier layer has reduced significantly the high
incidence of silicone bleeding seen in earlier generation
implants.
24,25
The surface texturing has minimized
implant rotation in anatomical implants.
The gel has become progressively more cohesive
through more extensive crosslinking of the silicone polymer. Cohesive gels are referred to as form stable (i.e., able
to maintain their shape without collapsing under their
Administration clinical trials were developed. After U.S.
Food a nd Dru g A dm in is tr at io n p an el h ea ri ng s a nd mul tiple other hurdles, the implants were approved again
for general use in 2006. Ongoing U.S. Food and Drug
Administration core group studies by Allergan Medical
and Mentor continue to collect data for a 10-year
span,10 and new data are being collected in postapproval studies that were required by the U.S. Food and
Drug Administration.
Interestingly, in the recent U.S. Food and Drug
Administration silicone breast implant follow-up panel in
August of 2011, there were still questions raised by antiimplant groups and individuals citing anecdotal reports
of autoimmune diseases caused by breast implants.
Despite over 25 high-level scientific studies and over 10
meta-analyses, all of which demonstrate no link between
breast implants and any autoimmune disease, there curiously remains a question of this association.
11 – 18
With
normal weight or being deformed by the surrounding
soft-tissue envelope). There is some evidence that form
stability has some long-term advantages in minimizing
implant-related complications.
Implant Shell
28 – 30
Essentially, there are two types of implant shell:
smooth and textured. Textured devices were originally developed to mimic the surface of polyurethane
implants that had a rough porous surface and were
known to have very low capsular contracture rates of
approximately 1 to 2 percent31; however, level I studies have not supported the lower capsular contracture
rates in textured implants.
26,32 – 44
In fact, there are as
many level I studies showing no dierence as there
are that show a benefit, likely indicating that surface
texture does not have a role in capsular contracture,
especially in the subpectoral pocket plane. The studies
16
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Breast Augmentation
are less conclusive for subglandular pocket plane, with
a possible benefit of texture in this position.
27,34,39,40
Coming full circle, the contracture benefit seen with
polyurethane implants was most likely a biochemical
eect not attributable to the surface texture. The current generation implant shells are much more durable,
and the introduction of barrier layers has reduced the
incidence of gel bleed significantly, a problem so often
associated with early generation prostheses.
Implant Shape
Implants are either round or anatomical. There is a
wide variety within these shapes. Most round implants
come in dierent projections for a given volume, allowing for better customization.
Anatomical implants come with even more variability of dimension because of their naturally asymmetric
shape. Therefore, width, height, and projection can all
be varied to optimally select a “best fit” implant.
There is much debate as to the relative merits of
other out of habit and familiarization with a particular
product. Our view is that surgeons should be comfortable in moving from one form to the other according
to patient desire and the anatomy of the individual.
Some situations will dictate a preference for anatomical and others for round.
Indications for round implants include the follow-
ing (Fig.1):
Fuller appearance.
Very small volumes (shape has less impact at small
volumes).
Good basic anatomy and skin quality.
Secondary surgery to avoid rotation.
Athletic individuals because of worry about
rotation.
Certain breast/chest wall shapes best suited.
Desiring an overfilled “Baywatch” appearance—
best achieved with round implant 50 to 100 cc
above optimal fill volume.
using round over anatomical devices and vice versa.
Many surgeons will tend to use one form over the
Indications for anatomical implants include the following (Fig.2):
17
Fig. 1. (Above) Before breast augmentation. (Below) After implantation with round 295-g implants.
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Breast Augmentation
Fig. 2. Preoperative (left)andpostoperative(right)viewsofbreastaugmentationwithanatomical295-cc
implants.
Patients who want a natural appearance and
implant that “fits” their breast.
Constricted lower pole breast (anatomical form-
stable implants).
18
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Thoracic hypoplasia.
Breast reconstruction.
Mild ptosis or pseudoptosis, although the rotation
risk increases with increasing envelope laxity.
Breast Augmentation
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THE PROCESS OF BREAST
AUGMENTATION
Breast augmentation is not simply putting an implant
into a pocket. The concept of breast augmentation
being practiced as a process has revolutionized this
procedure.
45 – 47
(See Video, Supplemental Digital
Content 1, which introduces the process of breast
augmentation, available in the “Related Videos” section
of the full-text article on PRSJournal.com or, for Ovid
users, at.)
A process is defined as a group of practices that
are completed successively to reach a goal. For 45
years, breast augmentation has been thought of as an
isolated surgical procedure; however, well-documented
elevated reoperation rates of 15 to 24percent over 2
years in successive premarket approval studies have
resulted in a critical analysis of this procedure.10
been demonstrated that the process is transferable and
45 – 47
reproducible.
The goals of breast augmentation are
as follows:
To enhance the breast, producing a result that is
pleasing and in proportion with the individual.
49
To minimize distortion through careful implant
selection.
To av oi d c omp l ic ati o ns th ro u gh go od te c hn iq u e.
To a ch ie ve re su l ts wi t h lo n ge v it y.
PATIENT EDUCATION
The most essential part of breast augmentation is
ensuring that patients have a good understanding of the
process. This includes an explanation of the principles
of implant selection—why a particular type, shape,
dimension, or size is used. (See Video, Supplemental
Factors that impact outcomes have been identified
and practice recommendations have been established
and refined.
48
This analysis has resulted in a redefinition of this procedure to a much broader process beyond the actual surgical placement of the implant. Essential components
include comprehensive patient education that enhances
informed consent, tissue-based preoperative planning,
refined surgical technique and rapid recovery, and a
strictly defined postoperative patient management plan.
Although each component may exist individually, the
combination of these steps in succession has resulted in
enhanced outcomes for patients far better than any one
component practiced in isolation. In recent years, as key
components of this process have been elucidated, it has
Digital Content 2, which discusses patient education
and informed consent, available in the “Related Videos”
section of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/A544.)
It is important for patients to have realistic expectations and to understand the limitations of the procedure and both short- and long-term consequences; this
includes knowledge of possible complications and the
need for reoperation. Patients will often arrive “well
informed” from Internet searches, and it is important
for the physician to add context and prioritize this
often random information. The goal of the surgeon
and the surgical team is to provide the patient with
the knowledge to make good decisions about their
breast augmentation.
Video 1. Supplemental Digital Content 1, which introduces the
process of breast augmentation, is available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/A543.
19
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Video 2. Supplemental Digital Content 2, which discusses patient educationand informed consent, isavailable in the “Related
Videos” section of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/A544.
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Breast Augmentation
ESSENTIALS OF PREOPERATIVE
ASSESSMENT
History
This should include the patient’s motives and
motivation for surgery. Establish whether goals are
realistic. Try to understand what appearance the patient
is hoping to achieve—natural versus obvious. This will
aect implant choice. It is also important to be cautious
about specifying cup size, as this is often inaccurate.
Concepts about shape and form are more useful.
A pregnancy history (i.e., if family planning is complete or if in the middle of trying to have a family) should
be obtained. In general, the best advice is to wait for the
completion of the family before proceeding with breast
surgery. It is also advisable to wait for 3 to 6 months
following the cessation of breast feeding for breasts to
return to normal before embarking on breast augmenta-
should be performed, including stature (Fig.3), height,
weight, structural asymmetries or deformities including
pectus excavatum/carinatum, sternal rotation, scoliosis
(Fig.4, above), and thoracic hypoplasia, which is the most
common but is often characterized as pectus excavatum
(Fig.4, center and below). The lie of the breast on the chest
wall (i.e., lateralization of nipple and breast) (Fig.5, above,
left) versus normal positioning (Fig.5, above, right) should
also be determined. The postoperative intermammary
distance is determined by the preoperative state. With a
properly sized implant, the patient with a normal intermammary distance will be normal (Fig. 5, below, left) and
patients with a wide intermammary distance will be
wide postoperatively (Fig.5, below, right). (See Video,
Supplemental Digital Content 3, which demonstrates tissue-based preoperative planning, available in
the “Related Videos” section of the full-text article on
tion or usually a minimum of 3 months of stable breast
size after breast feeding.
As breast size can vary greatly with fluctuations in
body weight, it is important to determine ideal weight
and to stabilize it before committing to surgery. A breast
cancer history is relevant in discussions relating to breast
cancer surveillance and to allay fears about cancer risk.
A general medical history should be taken, including
medication and smoking history, to establish that there
are no contraindications to surgery.
Physical Examination
One hundredpercent of women have asymmetries
between their breasts. General observation of the patient
PRSJournal.com or, for Ovid users, at http://links.
lww.com/PRS/A545.)
Skin quality, such as the presence of stretch marks
indicating thin inelastic skin, should be determined. It
is essential that any abnormalities are pointed out and
communicated to the patients. Often, patients will not
have noticed them preoperatively, and when picked
up postoperatively, the patient will be quick to blame
the surgeon.
Measurements
Basic measurements include nipple-to – sternal
notch distance, breast base width, breast height,
n i p p l e - t o – i n f r a m a m m a r y f o l d d i s t a n c e o n m a x
20
Fig. 3. Example of a more developed stature (left)versusathin,slightstature(right), which impacts the
decisions and postoperative outcome. A patient with slight stature and minimal breast tissue and tight
envelope (right)willrequirestricttissue-basedplanningtominimizenegativeeffectsoftheimplanton
tissues over time.
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Breast Augmentation
Content 4, which demonstrates essential breast augmentation measurements, available in the “Related
Videos” section of the full-text article on PRSJournal.
com or, for Ovid users, available at http://links.
lww.com/PRS/A546.)
These are the elements of tissue-based planning (i.e.,
the selection of the implant according to the dimension
of the breast and the quality of the tissues). Neither the
artist (no measurements) nor the engineer (only measurements) is ideal, but what has been proven scientifically to work best is a craftsman approach that uses
measurements to produce boundaries so that the artistic
sense can function.
TISSUE-BASED PLANNING FOR IMPLANT
SELECTION
Appropriate implant selection is critical for a good
outcome. In the past, this has often been a casual process without consideration for the consequences of poor
implant selection. The main driving force behind selection has been the volume of the implant with relevance
only to cup size leading to high reoperation rates where
the volume selection has not matched the tissue characteristics or the footplate of the breast.
Tissue-based planning relates to the concept of
dimension over volume. The observed dimensions and
measurements ultimately guide the appropriate choice
of implant. The principle is to identify the best fit for
a particular breast template causing as little soft-tissue
distortion as possible, optimally filling a breast while
respecting its natural boundaries. This approach has
been popularized by Tebbetts and remains the only
Fig. 4. Example of breast asymmetry secondary to bony asymmetries. (Above) Patient with scoliosis with asymmetric breast as
a result. (Center and below) Right thoracic hypoplasia with a unilateral chest wall concavity much more evident on the basal view
(below).
stretch, pinch test in the upper pole (2 to 3 cm or less
published tissue-based system that uses measurements
to determine optimal fill volume and an implant that
“fits” the breast.
45 – 47
Most implant manufacturers have a vast array of
implant shapes, profiles, and sizes, allowing an almost
tailor-made selection for each individual. Failure to
adhere to tissue-based planning and exceeding the
natural template can lead to an unnatural appearance,
soft-tissue distortion, and a host of other complications, leading to a higher incidence of reoperation and
poor outcome.
The Biodynamic system, devised by Allergan, is a
computerized system available in Europe in which the
physician enters a series of measurements, allowing the
software to compute a best-fit implant according to those
dimensions. The issue with this system is that it uses
external sizers tried on by the patient, which minimizes
is the index of submuscular placement), intermammary distance, chest girth, and skin stretch (envelope
assessment). (See Video, Supplemental Digital
21
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the earlier scientific and objective approach. Threedimensional photography is increasingly being used
for both patient and physician education as a means of
Breast Augmentation
Fig. 5. The position of the breast on the chest wall affects the outcome. (Above, left) Lateralized breast and nipple
versus more normal centralized breast (above, right). The postoperative intermammary distance, especially in the
subpectoral or dual-plane pocket, is determined by the preoperative state. (Below, left) Postoperative result of a
patient with a normal preoperative intermammary distance. (Below, right) Result with a wide preoperative intermammary distance.
assisting and engaging the patient in the decision-making process.
50
Classically, the most important dimension is the
width of the breast and therefore the width of the
implant itself. All of the other dimensions will further
guide the selection process. The width and skin stretch
measurements of the envelope are the two primary
measurements used to determine optimal fill volume.46
Va ri o u s c h es t w al l s h ap e s o r a n oma li e s w il l d ire c t the
precise selection of implant height and projection.
Other features such as degree of ptosis will also influ-
SURGERY
Preoperative Markings
The patient is marked preoperatively. The objective
of marking is to establish the existing foot plate and to
mark out the planned changes such as position of the
inframammary fold and placement of the inframammary incision, which should lie directly in the postoperative crease of the breast. (See Video, Supplemental
Digital Content 5, which demonstrates preoperative
markings, available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for Ovid
ence implant selection, favoring higher profile anatomical implants to inflate the hanging lower pole.
Where skin quality is poor and there is little breast
parenchyma, lower profile anatomical implants will be
preferred to avoid distortion of an already deficient
skin envelope.
22
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users, at http://links.lww.com/PRS/A547.)
Incisions
The most common are the inframammary and periareolar incisions. The transaxillary route51 is favored
by some, although many surgeons feel it is too remote
Breast Augmentation
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Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Vide
Video 3. Supplemental Digital Content 3, which demonstrates
tissue-based preoperative planning, is available in the “Related
Videos” section of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/A545.
from the breast pocket to adequately place the implant.
The so-called transumbilical breast augmentation is
restricted to inflatable saline devices.52 Table2 summa-
rizes some advantages and disadvantages of the various
dierent incisions.
Surgical Technique
The planes of dissection are generally either
subglandular or subpectoral in some form. (See
Video, Supplemental Digital Content 6, which
demonstrates the dissection sequence of the surgical
technique, available in the “Related Videos” section
of the full-text article on PRSJournal.com or, for
Vide
Video 5. Supplemental Digital Content 5, which demonstrates
preoperative markings, is available in the “Related Videos” section ofthe full-text article on PRSJournal.com or,for Ovid users, at
http://links.lww.com/PRS/A547.
Ovid users, available at http://links.lww.com/
PRS/A548; and Video, Supplemental Digital
Content 7, which demonstrates surgical dissection
pearls, available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for Ovid
users, available at http://links.lww.com/PRS/
A549.) The former is appropriate where there is
adequate tissue cover in the upper pole of the breast
(pinch test >1 cm). The subpectoral plane with
inferior pectoral origin release has been refined in
recent years by Tebbetts as the dual plane,
53
involving
subglandular dissection to varying degrees followed
by cephalad rotation of the pectoralis major without
atch Vide
Video 4. Supplemental Digital Content 4, which demonstrates
essential breast augmentation measurements, is available in the
“Related Videos” section of the full-text article on PRSJournal.
com or, for Ovid users, at http://links.lww.com/PRS/A546.
division of the main origins of the pectoralis muscle
along the sternum medially. Three types of dual
plane were originally described based on the inferior
edge of the muscle. Dual-plane I is division of the
inferior pectoral origins only (Fig. 6), dual-plane II
is division of inferior origins and release of anterior
pectoral fascial attachments to the gland with rotation
of the inferior origin at the level of the inferior
areolar border (Fig. 7), and dual-plane III involves
the inferior pectoral edge at the level of the upper
areolar border (Fig.8). (See Video, Supplemental
Digital Content 8, which demonstrates dual-plane
adjustment, available in the “Related Videos” section
of the full-text article on PRSJournal.com or, for
Ovid users, available at http://links.lww.com/
PRS/A550.)
The benefits of the technique combine good upper
pole/medial cover with improved draping of the lower
pole of the breast over the implant and a reduction in
23
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