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R. J. Zienowicz and E. Karacaoglu
Fig. 16.16 A 40-year-old woman with a history of breast
deformity that underwent augmentation mastopexy
5years ago. She had periareolar type mastopexy, and her
implants were placed in subglandular pocket. She had
signicant breast deformity, with areola widening. This
16.9 Conclusion
Mastopexy is possibly the most challenging aesthetic operation that endeavors to achieve an
ideal long-standing outcome. It is highly litigated
because of a widespread signicant lack of success and subsequent patient disappointment.
Preoperative size assessment for symmetry restoration and achievement of ultimate patient satisfaction are imperative. Three-dimensional
imaging for implant sizing—important in simple
augmentation—is just as important during breast
lift. Implant sizers confer similar predictability
and should always be employed.
patient underwent CVM with subpectoral placement of
implants bilaterally. (Left) Preoperative images. (Right)
Postoperative result at a follow-up appointment at 14th
month
References
1. Regnault P. Breast ptosis. Denition and treatment.
Clin Plast Surg. 1976;13:193–203.
2. Stevens WG, Stoker DA, Freeman ME, etal. Is onestage breast augmentation with mastopexy safe and
effective? A review of 186 primary cases. Aesthet Surg
J. 2006;26(6):674–81.
3. Calobrace MB, Herdt DR, Cothron KJ.Simultaneous
augmentation/mastopexy a retrospective 5-year
review of 332 consecutive cases. Plast Reconstr
Surg. 2013;131(1):145–56. https://doi.org/10.1097/
PRS.0b013e318272bf86.
Postpartum Breast Augmentation
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withImplants
JorgeAso andIsmaelGonzález
17
Take-Home Points
• Postpartum breast augmentation without mastopexy is indicated in patients with good skin
quality and absence of ptosis.
• The surgeon has to deeply explore the patient’s
expectations and clearly transmit the possible
outcomes and limitations of her case.
• The selection of the size is probably the single
most important item for the patient in the
whole decision-making process.
• Dual-plane technique is extremely useful in
post-maternity patients, since it combines the
advantages of both subglandular (glandular
lift) and submuscular (better coverage in the
upper pole).
17.1 Introduction
Beauty has been pursued since ancient times but
had its maximal evolution during the last century.
The progress of medicine and surgery and inuence of modern society extended the pursuit of
beauty to a lifelong moment; interestingly, we
can identify two concepts of beauty: one linked
to the classical beauty standards (typical of
youth) and the other linked to the research of
youth itself (typical of second and third age).
Pregnancy in particular is a moment in which
a combination of hormonal and mechanical factors may alter the female body shape.
Breastfeeding has erroneously been considered the main cause of breast changing after
pregnancy, and despite its proved importance for
the newborn’s health, many women avoid lactation fearing that it will affect their breast shape
and attractiveness.
It has to be claried that breast changes may
occur in different degrees or not occur at all after
pregnancy. The main risk factors for breast ptosis
are age, cigarette smoking (both of which are
associated with a loss of skin elasticity), larger
prepregnancy bra cup size, and number of pregnancies. While breast ptosis appears to increase
with each additional pregnancy, breastfeeding
does not seem to worsen these effects [1, 2].
Women willing to improve their breast shape
or volume after pregnancy have to be accurately
evaluated, and ptosis as well as tissue quality
should be correctly addressed before surgery in
order to avoid suboptimal results.
Breast augmentation without mastopexy is
indicated, as described in this chapter, in case of
good skin quality and absence of ptosis.
17.1.1 Available Breast Implants
J. Aso (*) · I. González (*)
Plastic Surgeon, Private Practice, Madrid, Spain
e-mail: info@doctoraso.com
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_17
Breast implant design has continuously evolved
since the rst creation, and use of a silicone gel-
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J. Aso and I. González
based prosthesis was reported in 1963.
Progressive understanding of implants’ biodynamic and technology evolution has brought us
to fth- and sixth-generation breast implants.
Three fundamental characteristics help in the
understanding of the majority of the devices:
shape, shell characteristics (surface design, surface material), and lling material. Slightly
more difcult is understanding the biodynamic
and the long-term interaction of each one of the
variables [3, 4].
17.1.1.1 Shape
With implant shape, we primarily dene the sagittal section of the implant shell. The two options
are “round” and “anatomical” (Fig.17.1).
Round-Shaped Implants
These implants were the rst one to be invented
and exclusively used for many years. The term
“round” is somehow improper, and it refers to the
equal convexity of the anterior surface of the
implant. The convexity increases proportionally
with the projection of the implant (but never
exceeds the diameter of the basis). The maximal
projection point is always at the center of the
implant. As a consequence of these characteristics, the base of the implant is round.
Anatomically Shaped Implants
The anatomical or “teardrop” implant is an evolution of the shape concept characterized by an
asymmetrical sagittal section in which the point
Fig. 17.1 Different effects on a post-maternity breast of
anatomical implants (left) and round (right). Note how the
anatomical implant has a maximum projection point in a
much lower position compared to the round one. This
helps when trying to align a slightly low-positioned NAC
and still getting a nice and natural result without the need
of a mastopexy
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299
of maximal projection is located in the lower half
of the device. The teardrop shape guratively
indicates the gradual increasing of projection
from the apex to the lower third of the implant;
this shape is more representative of a natural
breast in the upright position. The horizontal and
vertical dimensions are not important in the “anatomic” denition; any type of ratio is possible
between these two variants. The main drawback
of these implants is the possibility of rotation,
creating an abnormal shape.
17.1.1.2 Shell Characteristics
Surface Design
The importance of shell surface has progressively
increased during the years, and the implants of
rst generation were only smooth; however, in
the 1970s, it was observed that the newly introduced polyurethane-coated implant had a dramatically lower incidence of capsular contraction.
Even if the use of polyurethane was temporarily
dismissed for suspected cancer risk, the idea of
recreating a textured “polyurethane- like” surface
on silicone’s shell was implemented with the second generation of breast implants [5, 6].
There are several methods of texturization of a
silicone shell (salt loss, imprinting, etc.) and different grades of texturization. Producers have
independently developed and commercially
branded their own texturized products (AllerganBiocell, Mentor-Siltex, Motiva-Velvet, Polytech,
POLYtxt, etc.).
Texturization characteristics have recently
been reevaluated in the investigation of late-onset
complications such as breast implant-associated
anaplastic large-cell lymphoma (BIA-ALCL)
and late-onset seroma.
In order to carry out objective studies, several
standardized scientic nomenclatures have been
proposed. The three-dimensional surface area
ratio could ultimately clarify the nano, micro,
and macro-texturization concept dening four
roughness grades [7]. Other studies have focused
on the capacity of the implant surface to promote
bacterial proliferation [8].
Surface Material
The multilayer silicone shell has evolved during
the years thanks to experience and technology,
reducing the overall thickness of the shell and
increasing impermeability to avoid leakage
problems.
Independently of the lling, texturization,
and additional coating, all the breast implants
are made of silicone (laboratory product derived
from silicium, a likely inert, nonmetallic,
chemical element widely diffuse in nature).
After the 1995 FDA’s disclaim over polyurethane carcinogenicity, some producers started
to reintroduce additional polyurethane coating
to their texturized models. The main advantage
of polyurethane is the ingrowth of the capsule
in the polyurethane foam, which has been
proven to signicantly diminish capsular contraction rates [9].
17.1.1.3 Filling
After various attempts to nd an inert lling
material which closely resembles the consistency
of breast tissue, two lling materials have lately
been selected for their safety.
Silicone Gel
The silicone gel implant was the rst one to be
used, and gel production standards and characteristics have been improved during the years. Gellled implants have a more natural feeling if
compared to saline ones, and their cost is also
considerably higher. Fundamental feature of a
silicone gel is its grade of cross-linking, which
determines the cohesivity (attractive force
between the particles of a determined substance)
and viscoelasticity. These two factors determine
the capacity of maintaining a given shape and the
grade of resistance to temporary modications.
Cohesivity also avoids the spillage of the gel in
case of shell rupture.
Gel-lled implants are produced independently of the shape with different grades of silicone cross-linking. Specic anatomical implants
are lled with two gels with different cohesivity
(Polytech Diagon-gel, Allergan 510).
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J. Aso and I. González
Also related to the key concepts of viscoelasticity, the relatively new idea of “ergonomic”
prosthesis was recently introduced. A particular
viscoelastic gel in a round implant temporarily
changes its shape during the upright position
resembling a more natural anatomic implant
without the risks of a rotation.
Saline
Saline-lled implants are implants which contain
a saline solution; they are either pre-lled or
equipped of an ination valve (Baker implant);
they had an oscillating popularity during the
years. Despite the several drawbacks due to the
low cohesivity of the saline solution (rippling,
deation, somehow unnatural feel …), it was the
only available option in the United States during
the 1990s after the FDA moratorium on gel-lled
implants. The most effective strategy in order to
overcome the low density is to slightly overll,
giving in case of round implant even a fuller
appearance of the upper pole. After the withdrawal of the FDA moratorium in 2006, saline
implants have been used in a descending trend.
The main advantages of these implants other than
the absolute harmlessness of the saline solution
are the easy insertion even from a small incision
and the possibility of overcoming asymmetries or
patient’s higher volume desires with simple ination [4].
17.2 Patient Selection
A breast augmentation is a simple, low-risk procedure. Nevertheless, one has to keep in mind
that, as any other cosmetic procedure, only
healthy, adult patients should be considered for
the operation.
In very special circumstances, patients below
the age of 18 could also be considered (tuberous
or great breast asymmetries that produce psychological disorders), always with the clear consent
of the parents or legal tutors and a positive recommendation of a psychiatrist or a psychologist.
Patients should be warned that smoking can
greatly increase the possibilities of complications
after the procedure.
The surgeon has to deeply explore the patient’s
expectations and clearly transmit the possible
outcomes and limitations of her case. Every case
has a limitation (usually subtle), but this has to be
explained in a clear way to her. Failure to meet
expectations is undoubtedly the main source of
problems after the surgery.
The perfect patient is an adult, well-informed,
intelligent woman with reasonable and clear
expectations.
Anatomical requirements: The nipple has to
be at least at the same level as the IMF (preferably above). If the nipple stands in a ptotic
position (lower than the IMF), an augmentationmastopexy should be considered instead.
Key Points
Every case has a limitation (usually subtle), but this
has to be explained in a clear way to the patient.
17.3 First Consultation
andPatient Selection
17.3.1 Measurements
The rst step when assessing a new case is measuring the most important elements of the breast
(Fig.17.2):
• BBW: breast base width
• SN-N: sternal notch-to-nipple distance
• N-IMF: nipple-to-inframammary fold
distance
• Nipple-to-nipple distance
• Diameter of areolas
• NS: nipple-to-sternum distance
• BP: breast projection
• Nipple positioning in relationship to the IMF
height: above, same level, and below
17.3.2 Preoperative Planning
andSimulations
Some systems use the base width, skin stretch,
and nipple-inframammary fold distance to determine the implant size [10]. These considerations
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Fig. 17.2 Main measurements in breast augmentation
301
provide a safe and highly reproducible method
that minimizes complications. On the other side,
patient’s wishes and expectations are important
and they are to be considered in the implant
selection process, allowing patients to cultivate
ownership of the nal results [11]. The selection
of the size is probably the single most important
item for the patient in the whole decision-making
process. We always invest at least 20min in our
rst consultation on this particular matter.
During the rst consultation, the patient
undergoes both bra sizing and a 3D simulation.
The parameters of sizers and 3D simulator are
adjusted by the surgeon based on previously
determined breast measurements of the patient.
With this approach, the surgeon is able to provide
a range of acceptable implant volumes and projections, based on the patient’s measurements,
and then, eventually, choose the best one depending on the desire of the patient [12, 13].
Key Points
The selection of the size is probably the single
most important item for the patient in the whole
decision-making process. We always invest at
least 20min in our rst consultation on this particular matter.
17.3.2.1 Bra Sizers
This is the most commonly used sizing method in
breast augmentation. The process consists of
using external silicone sizers under the bra. The
patient is able to check the result in the mirror,
even with her favorite clothes on.
The surgeon changes the different volumes of
the size simulators to simulate the different projections within the width range of the patient’s
breast base.
We usually start by trying out the implant that
has the same breast width as the patient’s (minus
pinch divided by two) and full projection, since
this is the most commonly used implant used in
our practice.
The width of the breast limits the size of the
implants that we can use in a patient. In cases
where the patient wants more volume, we simulate extra-high projections superimposing two
sizers in one breast.
On the other hand, if a full projection implant
is considered too large by the patient, a moderate
one is simulated.
Some studies showed that the patients that
underwent bra sizing felt that the nal breast size
was smaller than predicted by the sizer process
[14]. This is mainly caused by two factors:
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1. The patient is not used to having a bigger
breast. First impression causes the patient to
feel that “maybe this is too much.”
2. Over time, some breast gland atrophy is
expected, and the swelling will fade away,
creating the perception of a smaller breast
than before.
Thus, we always try to convince the patient to
choose the largest implant volume with which
they feel comfortable.
Key Points
We always try to convince the patient to choose
the largest implant volume with which they feel
comfortable.
17.3.2.2 3D Imaging Simulator
The 3D simulator is a very useful tool to calculate the size and shape [15–17]. One study
showed that 90% of patients agreed (66% absolutely agreed, and 24% partially agreed) in that
the nal product after breast augmentations was
similar to the 3D simulation. The majority of
patients felt that the simulated images were
accurate in predicting their actual results and
shape [18].
In our experience, it is very useful not only in
calculating the size, but also in showing the difference between round and anatomic implants in
the patient. Thus, the patient can decide what
type of implant she prefers, being aware of the
advantages and disadvantages of each type of
implant (especially the risk of rotation in the anatomical ones).
However, we have to be very careful with the
use of this 3D simulation. Final result may
diverge from the simulated image, and patients
may be disappointed or may lodge a complaint.
We always stress the fact that medicine is not an
exact science and that a 3D simulation is a tool to
show where the efforts are directed and never,
ever, shows guaranteed results. No image or le
of the simulation is sent to the patients, since this
could be legally considered a guaranteed result.
17.4 Anesthetic Considerations
17.4.1 Surgical Technique
17.4.1.1 Patient Positioning
The patient is placed in decubitus supine. The
upper limbs can be adduced (and secured to each
side by sheets placed under the body) or abducted
(90°). Both positions are possible, our preference
being the adduced one, since it gives a more natural and real effect of the augmentation once the
implant is in place.
17.4.1.2 Implant/Pocket Plane
A good and safe result in implant breast augmentation is a combination of two factors (other than
a proper indication!).
– Election of the right implant based on patient’s
anatomy and desires
– Right plane to position the implant, which is
still inuenced by patient’s anatomy but not
driven by a standard algorithm and still based
on surgeon’s preference and experience
There are basically three possible implant
positions: submuscular, subglandular/subfascial,
and partial submuscular.
Submuscular
The conventional called “submuscular position”
consists of a pocket dissected between the thoracic wall and the posterior surface of the pectoral major muscle. As a matter of fact, this pocket
is not completely submuscular since about onefourth of the implant will extend beyond the
lower lateral margin of the pectoralis major due
to its normal anatomy. Complete submuscular
procedures are described and involve the additional dissection of the serratus and lateral
oblique muscles. Advocates of the submuscular
positioning believe that especially in skinny
patients with scarce glandular tissue and thin
subcutaneous coverage, the muscle gives an extra
soft tissue protection, thereby a more natural
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feeling and lower rippling and capsular contracture incidence. Dynamic breast and early waterfall deformity are the considerable disadvantages
of this procedure. Our preference is to use the
total submuscular plane only for breast
reconstruction.
Subglandular
The subglandular/prepectoral position consists of
a pocket dissected between the posterior surface
of the breast’s gland and the anterior surface of
the pectoral’s muscle. The subfascial variant
involves the positioning of the implant between
the pectoralis fascia and muscle bers. The main
benet of the subglandular position is a favorable
prosthesis glandular interface for low-grade ptosis correction (especially when using anatomic,
full, and extra-projected implants). The subglandular placement allows the implant to be in close
contact with the gland, tightening the lower pole
of the latter, and, thus, correcting partly a low
nipple-areola complex (NAC) without the need
of a mastopexy. Moreover, a prepectoral implant
will drop over time with the gland, as opposite to
the submuscular plane, in which the gland will
drop and the implant will stay high (waterfall
deformity).
Other advantages of this plane are:
– Absence of dynamic breast
– Lower surgical site morbidity
– Faster recovery (less pain) and complete pres-
ervation of muscular function
The more natural shape advocated by some
surgeons is for us a relative concept being
strongly inuenced by implant and patient characteristic. Equally, we do not believe that the subfascial plane guarantees a consistent improvement
in implant coverage but may play a protective
role for implant contamination.
Apparent higher capsular contraction rate,
palpable implant’s edges (or even visible upper
pole of the implant in thin patients), and rippling
are the main drawbacks of this technique [19].
We recommend the subglandular implant
position only in case of really good soft-tissue
coverage (pinch test at medial and upper pole
>4cm). This is mandatory in young women with
desires of a future pregnancy, since the soft-tissue
thickness would likely undergo a signicant or at
least unpredictable thinning.
Partial Submuscular/Biplanar
The partial submuscular implant placement was
developed in order to combine advantages of
both submuscular and subglandular placement:
implant coverage in the upper and medial quadrants, favorable lower pole implant-soft tissue
interface for mild ptosis and/or constricted lower
pole correction, reduced dynamic breast, and
capsular contraction.
Dual Plane
In this technique, the interface between muscle and
breast is variably dissected until the upper border of
the areola is proportional to the grade of ptosis tendency/lower pole constriction. The pectoral muscle
is completely divided along the rib insertions along
the inframammary fold, and a subpectoral pocket is
prepared. The inferior release of the muscle and the
additional breast- muscle interface dissection allow
the muscle to shift cranially leaving the inferior
portion of the implant directly under the glandular
parenchyma (Fig.17.3).
According to Dr. Tebbetts [20], any breast
augmentation should meet the following criteria:
1. The implant lies partially behind the pectoralis major muscle and partially behind the
breast parenchyma (in dual planes
simultaneously).
2. A specic group of pectoralis major muscle
origins is totally divided in a specic area to
alter implant-soft tissue dynamics by anatomically repositioning pectoralis major portions
relative to the implant (this criterion distinguishes dual-plane from partial retropectoral
augmentation).
3. The parenchyma-muscle interface is specically altered to change the soft-tissue relationship between the pectoralis major and
parenchyma and to change the implantparenchyma dynamics.
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Parenchyma-
Types
(Type II)
(Type III)
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Muscle (PM)
Interface
Separation
Pectoralis
Muscle
Divsion
Lateral View
Pectoralis
Position
Related to
Anatomic
Implant
Parenchyma
No PM interface separation PM interface separation to inferior
No
Division
Complete division
along IMF
edges of areola
No
Division
PM interface separation to superior
edge of areola
No
Division
Type III
Apply tp
Following
Breast
Most routine breasts
(Type I)
Fig. 17.3 Different types of dual-plane levels. Left column: dual plane I; center column: dual plane II; right column:
dual plane III
This technique is extremely useful in postmaternity patients, since it combines the advantages of both subglandular (glandular lift) and
submuscular (better coverage in the upper pole).
Muscle Splitting
Muscle splitting augmentation is a procedure in
which a pocket is created simultaneously in the
subglandular and submuscular planes, with the
implants lying behind and in front of the pectoralis muscle at the same time, without pectoralis
Type I
Type II
Breasts with
mobile parenchyma-
muscle interface
Glandular ptotic
and constricted lower
pole breasts
division along the costal margin. It is basically a
variant of the dual-plane technique in which the
pectoral muscle is directly incised at the nippleareola complex leaving the inferior part of the
muscle attached to the rib cage. Submuscular
dissection is limited to the upper part of the split
pectoralis major. The advocated advantages
compared to the dual-plane technique are the
lower risk of dynamic breast and faster recovery
due to limited submuscular dissection
(Table17.1) [21, 22].
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Palpability/visibility of implant,
especially in the upper pole
Higher risk of visible rippling
Direct effect on the gland (more
NAC “lift”)
Less control of the IMF
Risk of
waterfall
deformity Other considerations
−
Recovery
time
Higher risk of waterfall deformity
Less effect on nipple-areola “lift”
the lower pole)
Good control of the IMF
The implant “lifts” more than total
submuscular due to direct effect on
lower pole
Subglandular placement advantages
and trade-offs with better tissue
coverage
Variability in fat graft survival may
lead to suboptimal results
Possible donor-site complications
−
305
Operative
time
+ +
Animation and
implant
displacement
−
a
Capsular contraction
rate
May be higher,
especially with
smooth implants
−
Implant coverage
↑ upper poles
−
↓ lower poles
↑
↓
+++ + +++ +++ Good implant coverage
May be lower,
especially with
smooth implants
++
++
↑
↓
+/++ + ++ ++ Good implant coverage (except in
May be lower,
especially with
smooth implants
−
↑ ++
↓
+++ ++
−
Not enough data
available but may be
same as subglandular
+/++
−/+
↑
Depending on grafted
volumes and treated
zones
↓
Table 17.1 Implant location: benets and trade-offs. More + = longer time
Subglandular
Total submuscular
Partial submuscular
(dual plane)
Combined
(fat graft +
subglandular
implant)
Capsular contraction related to implant location is somehow controversial due to heterogeneity of past studies and lack of up-to-date evidence-based reports on last-generation
breast implants
a
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