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Breast Augmentation
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Table 2. Advantages and Disadvantages of Incisions
Incision Advantages Disadvantages
Inframammary Most control; ability to manipulate/set IMF; least
implant effects (trauma and contamination)
Periareolar Good access to breast; scar can be very well
disguised usually
Transaxillary No scar on breast Remote from pocket; tends to promote blunt
IMF, inframammary fold; NAC, nipple-areola complex.
pectoralis animation because of separation of muscle
and gland and inferior origin division. Other benefits
of the subpectoral plane include increasing evidence of
lower capsular contracture rates54 and good mammographic visibility of the breast. Indeed, these are limitations of the subglandular plane and the fact that, over
time, glandular atrophy and compression are probably
capsular contracture rates, adding to the biofilm theory
as being an important factor in capsule formation.58 (See
Video, Supplemental Digital Content 9, which
demonstrates pocket irrigation and pocket preparation,
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/A551.)
Scar not ideal unless planned properly
Can result in poor scarring; higher capsular
contracture rates; contamination theory; NAC
sensitivity more affected
dissection; less controlled pectoralis major
release unless endoscopically assisted; dual-plane
dissection not possible
more likely in the subglandular plane rather than in a
dual plane.
The total submuscular plane has few indications and
is an unnatural plane, involving elevation of the serratus
fascia in continuity with the subpectoral plane. The subfascial plane has also been described, although debate
exists as to whether this confers sucient benefit or
upper pole cover to justify its widespread use.
Pocket Preparation and Irrigation
55
Pocket irrigation is an essential step before placement of the implant.
56,57
Evidence points to the benefits of irrigation with antimicrobial preparations such
as multiple proven antibiotic combinations in lowering
Implant Placement
With silicone implants, an adequate incision size is
required to minimize implant shell trauma. The larger
the volume of the implant, the larger the incision. Formstable implants require incisions 0.5 to 1.0 cm larger
than round non – form-stable implants.
Postoperative Management
A defined postoperative regimen is essential to optimizing outcomes and is the final part of the process of
breast augmentation. Patients are usually placed in a
sports/surgical bra for periods of up to 6 weeks after
surgery for comfort and postsurgical support. Early
Video 6. Supplemental Digital Content 6, which demonstrates
the dissection sequence of the surgical technique, 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/A548.
24
Vide
atch Vide
Video 7. Supplemental Digital Content 7, which demonstrates
surgical dissection pearls, is available in the “Related Videos” section ofthe full-text article on PRSJournal.com or,for Ovid users, at
http://links.lww.com/PRS/A549.
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Breast Augmentation
Watch
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Watch Video
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Fig. 6. Dual-plane I, division of the inferior pectoral origins only.
(Reprinted from Adams WP Jr. Breast Augmentation. New York:
McGraw-Hill; 2011.)
mobilization and movement is encouraged to allow for
the pectoralis to stretch naturally, thereby minimizing
postoperative contraction and discomfort.
COMPLICATIONS
The following is a list of complications/issues that
need to be discussed with pa
tients:
Bleeding/hematoma (1percent risk).
Infection (should be <1percent risk).
Use of drains.
Seroma.
Fig. 8. Dual-plane III, with the inferior pectoral edge at the level
of the upper areolar border. (Reprinted from Adams WP Jr. Breast
Augmentation. New York: McGraw-Hill; 2011.)
Sensory changes to the nipple and or breast (com-
mon in the short term).
Scarring.
Asymmetry.
Implant visibility/palpability.
Implant rippling.
Malposition of the implant.
Implant rupture (1 to 2percent at 10 years).
Implant rotation (anatomical) (2percent).
Soft-tissue stretch (stretch marks).
Glandular atrophy (over time).
Galactorrhea.
Capsular contracture (5 percent for textured
Fig. 7. Dual-plane II, division of inferior origins and release of
anteriorpectoral fascial attachmentsto theglandwith rotationof
the inferior origin at the level of the inferior areolar border. (Reprinted from Adams WP Jr. Breast Augmentation. New York:
McGraw-Hill; 2011.)
silicone).
Vide
Video 8. Supplemental Digital Content 8, which demonstrates
dual-plane adjustment, is available in the “Related Videos” section ofthe full-text article on PRSJournal.com or,for Ovid users, at
http://links.lww.com/PRS/A550.
25
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W
atch Vide
o
Watch Video
Breast Augmentation
Video 9. See Video, Supplemental Digital Content 9, which
demonstrates pocket irrigation and pocket preparation, 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/
A551.
Anaplastic large cell lymphoma (implant related).
Need for reoperation at some stage in the future
(approximately 20percent at 10 years).
Mammography plus breast cancer detection.
Silicone controversy.
Financial implications for the future.
Reoperation and Breast Augmentation
One of the goals of breast augmentation should be to
try to keep reoperation rates to a minimum. Recent U.S.
Food and Drug Administration studies from Allergan
Fig. 9. Capsular contracture is caused by inflammation around
the implant. The most common cause and greatest factor is subclinical infection/bacteria/biofilms. The end result is the net sum
of the potentiators and suppressors of capsular contracture.
Implant technology. This continues to improve to pro-
duce more durable and more reliable devices. Shell
technology has reduced capsular contracture rates,
and gel form stability has improved the relationship
between the implant and the breast itself.
Treatment of capsular contracture includes the
following (Fig.9):
and Mentor10 point to reoperation rates of up to 20percent for primary breast augmentation and significantly
higher for secondary surgery.
Reasons for reoperation are multifactorial. Some factors are avoidable and some are not. Avoidable factors
include the following:
Poor implant selection.
Oversized implants, leading to soft-tissue stretch,
glandular atrophy, and capsular contracture.
59,60
Wrong implant shape selection, leading to dissatis-
faction with outcome.
Surgical technique (e.g., plane selection, minimal
trauma, accurate pocket dissection, hemostasis, minimal implant handling, pocket irrigation,
appropriate surgical environment).
ried out.
39
biofilm on old ones).
30
61
to subpectoral/dual plane.
54
described.
-
sules considered (not available in the United States).
Anaplastic Large Cell Lymphoma
62
This condition has been reported associated with
breast implants in the past 2 years. Patients with breast
Unavoidable factors include the following:
Changes in patient circumstances (e.g., pregnancy,
weight gain, weight loss, aging).
26
implants have virtually all behaved paradoxically compared with other patients with this diagnosis. In fact, it
appears that there may be a new classification of a breast
implant – associated anaplastic large cell lymphoma or
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Breast Augmentation
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lymphoid hyperplasia that has a much more benign
course. The majority of cases have presented with late
seromas that may also implicate the role of bacteria and
biofilm in this condition. Treatment in most cases has
been capsulectomy and implant removal only.
63 – 65
CONCLUSIONS
Breast augmentation is much more complicated
than initially perceived. Using the process of breast
augmentation including structured patient education,
tissue-based preoperative planning and implant selection, refined surgical technique, and defined postoperative care, improved patient outcomes have been
demonstrated. Implementing these practice recommendation will likely expand the breast augmentation market as more patients see the benefits of these
new advances.
William P. Adams, Jr., M.D.
6901 Snider Plaza, Suite 120
University Park, Texas 75205
prs@dr-adams.com
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Breast Augmentation
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View Article
CME
David A. Hidalgo, M.D.
Jason A. Spector, M.D.
New York, N.Y.
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ME
Learning Objectives: After studying this article, the participant should be
able to: 1. Assess patient physical characteristics that influence implant selection. 2. Adopt a system to aid in implant size selection. 3. Become cognizant
of the advantages and disadvantages of incision, pocket plane, and implant
options. 4. Understand implant positioning concepts and aseptic implant
handling methods. 5. Manage untoward postoperative sequelae 6. Understand secondary surgery concepts.
Summary: Breast augmentation is the most commonly performed aesthetic surgical procedure. Choices of incisions, pocket plane, and myriad
implant characteristics constitute the basis for surgical planning. Analysis
of physical characteristics and inclusion of the patient in implant selection
contribute to overall satisfaction and reduce requests for secondary surgery.
Technical expertise in implant positioning and aseptic handling helps to
prevent capsular contracture, implant malposition, and other shape problems. Despite the need for secondary surgery in some, patient satisfaction is
high. (Plast. Reconstr. Surg. 133: 567e, 2014.)
reast augmentation is the most common aesthetic
surgical procedure, with more than 300,000 per-
B
plane, and implant characteristics, including shape, texture, filler, and volume, constitute the key decisions in
surgical planning. Thoughtful analysis of physical characteristics and patient participation in the process are the
most important factors in size selection. Knowledge of
implant positioning and aseptic handling concepts contributes to successful outcomes and minimizes the need
for secondary surgery. Patient satisfaction is high with
this procedure, despite significant reoperation rates to
treat capsular contracture, implant deflation, malposition, and other problems (References 2 and 3: Level
of Evidence: Therapeutic, IV).
formed in 2011.1 Choices of incisions, pocket
2,3
ESSENTIALS OF PREOPERATIVE
and occupation reflect personality and aesthetics. Anatomic limitations must be explained to the patient.
Height and weight influence implant selection. For
example, tall patients require larger volumes than short
patients to achieve a similarly proportioned result. Thin
patients are not well suited to saline implants. Idiosyncrasies in body morphology also play a role: patients with
wide hips or shoulders look better with larger implants
compared with those who are narrower.
Chest wall shape is important to note.6 Pectus excavatum occurs occasionally, whereas pectus carinatum
and Poland’s syndrome are rare.7 Central deformities
are typically ameliorated suciently by breast augmentation alone. Deep pectus excavatum deformities can
be treated simultaneously with a custom solid silicone
implant made from a plaster moulage, but most patients
decline this option. Poland’s syndrome, when severe, may
5
Patient Evaluation
Each patient’s psychology, aesthetic sense, and anatomy must be critically assessed. Emotional stability is a
mandatory prerequisite.4 Style of dress, makeup, tattoos,
piercings, previous aesthetic procedures, community,
From the Division of Plastic Surgery, Weill Cornell Medical College.
Received for publication April 9, 2012; accepted September 21, 2012.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000033
30
ASSESSMENT AND MANAGEMENT
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Disclosure: Neither author has a financial interest in any of
the products or devices mentioned in this article. This work was
not supported by outside funding.
Related Video content is available for this article. The videos
can be found under the “Related Videos” section of the fulltext article, or, for Ovid users, using the URL citations published in the article.
Breast Augmentation
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require adjunctive procedures, such as tissue expansion,
fat grafting, and latissimus muscle transfer.
7,8
A round
thorax shape makes the breast axes diverge, causing the
breasts to appear farther apart following augmentation.
A rectangular thorax makes the axes parallel, so that the
breasts appear closer together postoperatively.
9
Hemithorax asymmetry due to dierences in shape or relative
protrusion can create an uneven breast foundation, suggesting dierent size implants despite equivalent breast
volumes (Fig. 1).10 Scoliosis can cause vertical breast
asymmetry requiring thoughtful implant positioning to
minimize it.
11
Existing breast volume influences implant filler
choice. Small volume is not very compatible with saline
implants, but as volume increases, there is less dierence
between saline and silicone.
Breast shape may limit implant selection. Vertically
prone to double-bubble deformities as implant diameter increases.
15
Tissue characteristics and skin quality are equally
important factors. Postpartum patients with atrophic
tissue and poor skin elasticity make visual and tactile
implant concealment challenging, and also pose a risk
of late lower pole descent. Conservatively sized silicone
implants are the best choice in these patients. A concomitant mastopexy allows excision of some of the inelastic lower pole skin and enables placement of a smaller,
lighter implant in more extreme cases.
Nipple hypertrophy and ptosis, common in postpartum patients, may be improved by circumferential skin
excision at the nipple base. (See Video, Supplemen-
tal Digital Content 1, which demonstrates a nipple
reduction. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com
short breasts are prone to lower pole deformities as
implant diameter increases. Similarly, breasts with constricted base diameters, such as tubular breast deformity, are challenging to aggressively augment and may
require a more complex treatment strategy.
12 – 14
Inframammary crease anatomy is also important.
Minimal crease definition imposes little restriction on
implant diameter selection, and therefore size. Glandular ptosis with a sharply defined crease located close to
the areola represents the opposite extreme. This type is
or, for Ovid users, at http://links.lww.com/PRS/
A952.) Reduction in both height and diameter can be
achieved by the top-hat reduction method.
16
Treating
this condition is simple and enhances the overall result.
Nipple-areolar position asymmetry is magnified by
breast augmentation (Fig. 2). A unilateral circumareolar mastopexy or a Y-scar mastopexy can be considered
depending on the severity of the problem.
17
The larger the areolar diameter, the more it tends to
stretch following surgery. Conservative circumareolar
Fig. 1. Chest wall shape can aect the axes of the breasts and their relative
projection.
31
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Breast Augmentation
Watch
o
Watch Video
Vide
Video 1. Supplemental Digital Content 1, which demonstrates nip-
ple reduction, is available in the “Related Videos” section of the fulltext article on PRSJournal.com or, for Ovid users, at http://links.lww.
com/PRS/A952.
excision should be considered with diameters approaching 6 cm. Circumareolar excision must be coupled
with a periareolar purse-string suture, typically with
nonabsorbable suture material, in order to provide a
lasting result.
Implant Selection
Size (volume and diameter) is arguably the most critical aspect of implant selection, followed by filler type.
Second-tier factors include shape, profile, and surface
texture.
The dierences between textured and smooth
implants have been debated (Reference 19: Level
of Evidence: Therapeutic, I).
18,19
Current evidence holds that smooth implants are more prone to
capsular contracture in the subglandular plane.20 A
dierence between the two types has not been proven
19
in the subpectoral plane.
Smooth implants are currently used in approximately 90percent of patients in
the United States.
21
Round implants are used in 95percent of patients
in the United States today.21 Superior aesthetic results
32
Fig. 2. (Left) Preoperative nipple-areolar position asymmetry. (Right) The asymmetry is magnied following augmentation, but within acceptable limits.
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Breast Augmentation
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Selection of saline versus silicone filler is influenced
by anatomy, as previously described. Advantages of
saline implants include smaller incisions with possible
remote locations, no special long-term monitoring, and
results that may endure for decades. Silicone implants
have less wrinkling and palpability, and no risk of deflation. Approximately 60percent of implants used in the
United States today are gel filled.
21
Size is usually the most important implant variable to
the patient. Magazine photographs, cup sizes, and friends’
experiences are not reliable measures for determining
size. One recommended method computes optimal
size based on breast base width, anterior skin stretch,
upper pole pinch thickness, inframammary fold pinch
thickness, and stretched nipple-to-fold distance.
24 – 26
This
Fig. 3. A 300-cc standard prole implant is shown on the left. The
300-cc implant on the right has a higher prole but a smaller di ameter in comparison. It also appears to be lled tighter and does
not exhibit the wrinkling evident in the standard prole implant.
The latter feature is an indication for its use in thin patients.
using anatomic implants remain unproven. Implant
rotation requiring additional surgery can occur with
these devices (Reference 23: Level of Evidence:
22,23
Therapeutic, IV).
Unlike in breast reconstruction,
a dierent scenario, there is no clear role for anatomic
implants in breast augmentation.
Implant profile is a variable that aids in achieving maximum volume in patients having narrow chests, breast
base diameters, or both. Higher profile implants have
smaller diameters that allow placing maximum volume
in these cases. Patients with wide chests or breast base
diameters do best with regular profile implants (Fig.3
and Table1).
analytic method determines optimal implant dimensions
based on individual anatomic characteristics.
Preoperative sizing is another method that is more
subjective in its approach. It consists of placing sample
implants in a bra to preview a range of possible results.27
The surgeon first determines a size range suggested by
height, weight, and body habitus that is also mindful of
breast anatomy restrictions. This process shares ownership of the final decision between the patient and the
surgeon. It has been shown to minimize requests for
size-change surgery.
Patient Education
27
Comprehensive patient education should include
implant options, associated risks, anatomical restrictions, and potential problems that can lead to secondary surgery. Given that implants are prosthetic medical
devices, providing informed consent requires imparting
considerable information. Providing a written document in which the patient initials each paragraph is one
eective way to disclose all possibilities and ensure that
the information has been received (see Appendix).
Table 1. Implant Prole Selection
Normal height
Allergan Natrelle moderate
Mentor moderate
Sientra low projection
Intermediate height
Allergan Natrelle moderate
plus
Mentor moderate-plus
Sientra moderate
projection
33
Adequate parenchymal
volume
Wide chest
Breasts far apart
Long lower pole
Tall patient
Large areolar diameter
(correction not planned)
Thin tissues
Wrinkling or knuckle with
normal height implant
Narrow chest
Maximum volume with nar-
row breast base diameter
Maximum volume and
minimum lateral fullness
Petite patient
Besides size, implant filler type is a key decision for
the patient. When informed that the notion that silicone
Table 2. Patient Education: Saline versus Silicone
Implants
Saline Silicone
Appearance Same Same
Delectability to touch More noticeable Less noticeable
Wrinkles/ripples Possible Rare
Palpable “knuckle” Rare Possible
Spontaneous deflation 5% chance Does not occur
Silent rupture Does not occur Typical
Incision Short Slightly longer
Cost Less More
Monitoring None MRI scans needed
Overall frequency of use Less More
MRI, magnetic resonance imaging.
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