Breast Augmentation

Description of the Problem

Breast augmentation is performed for women who feel that their breasts are too small (hypoplastic). In most cases there is only a need for additional volume but sometimes a mild droop can be completely corrected by the addition of an implant.

After liposuction, breast augmentation is the procedure most frequently performed by plastic surgeons.
If a breast is small and there is a significant droop, it may be necessary to carry out a breast lift at the same time as the augmentation. Then, both the form and the volume can be addressed.

When discussing the problems and solutions for breast hypoplasia, it is important to realise that the final result is significantly affected by the quality of the overlying skin and consistency of the breast tissue. The better the skin and the thicker the underlying subcutaneous fat, the more coverage of the implant and the more natural the result will be.

Aim of the operation

The goal is to increase the volume of the breast and/or to tighten the overlying skin. If a lift is also performed, the nipple will be moved upwards to a more aesthetically pleasing position.

In order to increase the size of the breast a number of techniques are available:

1. Implant
2. Fat transfer or ‘lipofilling’
3. Combination of implant and lipofilling (composite breast augmentation)
4. Microsurgical tissue transfer
5. External expansion

The Surgical Technique

Implant based breast augmentation

Breast implants are like small balloons. The outer layer is soft and elastic but very strong. Different styles of implants have outer layers which differ in terms of their thickness, texture and flexibility. Some have an additional outer coating of titanium or polyurethane foam.

The prosthesis is filled with either saline (salt-water) or silicone gel. In the past, liquid silicone gels caused problems when the outer shell ruptured. These days the gel is cohesive so that even if there was no outer shell, the gel would stay together. It is soft and malleable, but not fluid.

The shapes and volumes of implants vary greatly. Some are round while others have a tear-drop profile. There are numerous manufacturers and surgeons may have their preferences but will discuss these options with their patient. Although many varieties are available, in our opinion, an implant that is too big will lead to a less natural result and very large implants can lead to increased complications.

The surgical technique is straightforward. Through a small incision, a pocket is made behind the breast and the prosthesis inserted. The most common sites for the incision are (fig. 1):

• Near the armpit
• In the crease under the breast
• Around the areola

Fig. 1 

Implants can be placed via the navel, but this is technically difficult and the results are therefore often not as good. This and the armpit incision are only really suitable for saline-filled implants. If they later need to be corrected, the subsequent incision would have to be in the breast crease or nipple. Areola incisions settle well, but sometimes affect the sensation to the nipple. It is for these reasons that the incision in the crease under the breast is our preference.

The implant may be placed either over (fig. 2) or underlying (fig. 3) the pectoral muscle. If there is enough breast tissue and good quality skin, the implant is best placed underneath the gland. If the overlying tissue is thin, the implant is better placed underneath the muscle. Sometimes a combination of these two locations is the best way to achieve a good result. The position of the prosthesis has little bearing on the risk of complications.

Fig. 2: Position in front of pectoral muscle	Fig. 3: Position behind the muscle

Finally, sometimes a surgeon will decide to leave a small drainage tube coming out through the skin to avoid any collection around the breast implant. This will be removed after one or two days.

Augmentation through lipofilling

With this technique, fat cells are removed from another part of the body, processed to isolate them from their surrounding liquids and injected into the breast just underneath the skin. The main advantage is that no foreign material has to be inserted and that rejection cannot occur. However, not all of the cells survive the procedure and only around 40-60% will remain. Once it has survived after 6 months, it will last a lifetime. The drawback is that only a limited amount can be injected on each occasion. Around 100-150cc is the maximum. Only very small scars are left where the fat is harvested and where it is injected. Although the technique is not very complex, it is very time-consuming.

The ideal patient for this procedure is a young woman with excess fat around the abdomen or hips who has small breasts and only desires a modest increase in their size.

More information can be found on www.lipofilling.com

Composite Breast Augmentation

The prosthetic breast implant may be the single most important device ever developed in the field of plastic and reconstructive surgery. Despite half a century’s worth of technological advances, the revision rate for breast prostheses remains high: 24% at 4 years and 36% at 10 years. Many revisions are performed for soft tissue related problems and not for failure related to the device per se. Soft tissue problems include capsular contracture and chronically atrophied and inadequate overlying tissue sometimes causing visibility of the device, a condition we define as "soft tissue failure". Simply stated, one of the major drawbacks of breast implants is their unnatural appearance when the overlying soft tissue volume to implant volume ratio is out of balance.

Early work with lipofilling focused on core volume enhancement but there is a natural limitation to the projection achieved with fat alone, due to its soft nature. Making the analogy to “mountains of sand”, breast projection using only fat comes at the cost of a wide breast footprint, often wider than desired.

Over the last 5 years we have successfully been using a combination of classic implant and simultaneous management of the overlying soft tissue with lipofilling - a concept we define as composite breast surgery. By incorporating both mediums, one may achieve the core volume projection of an implant complemented by the natural look and feel of a fat overlay.

The technique is simple: the implant is placed in a pre-muscular plane, avoiding post-operative movement of the implant with movements of the arm. Also, this positioning is much less painful. Lipofilling is mainly added on the superior border of the implant to increase the soft tissue coverage of the implant. Fat can also be added in the other quadrants of the breast to improve the implant versus soft tissue ratio. Smaller implants with thicker soft tissue coverage will be less prone to long term complications.

Figure 4. Frontal and lateral views of implant insertion in composite breast augmentation. Deep lipofilling, just in front of the muscle (blue) and subcutaneous lipofilling (yellow) are mainly performed on the upper and medial border of the breast to cover the border of the implant and to provide a natural appearance of the décolleté area.,

Augmentation using microsurgical techniques

Our experience in the field of breast reconstruction allows us to use tissue from the buttock or abdomen to add volume to the breast.
A detailed explanation of these techniques is available in the reconstruction section. Briefly, a piece of skin and fat can be taken from the abdomen, the buttocks or the inside of the thigh, following detachment of its blood supply. This is then re-attached to another vessel adjacent to the breast, so that the transplanted tissue survives on its new blood supply.
The main disadvantage is that this is a long, complex procedure and leaves a major scar at the donor site. However, it has the advantage of providing enough tissue in one operation to increase the size of both breasts by between 300 and 800cc. The tissue is your own and no immune rejection will occur and again the tissue will last a lifetime.
The ideal patient for this approach would be a lady who would deem the tummy-tuck that is performed at the donor site as an advantage. This is particularly the case after multiple pregnancies, weight loss or as one enters middle age. 

Augmentation by external expansion

This went through a phase of being popular some years ago. An external expander applied suction to the outside of the breast to achieve an increase in size. However, the results proved to be unpredictable and short lived and therefore the technique is now rarely performed. 

Breast augmentation in combination with a mastopexy

The details of a breast lift have previously been covered. It allows the position of the nipple to be moved and the implant is inserted through the vertical scar of the mastopexy.
Combining an augmentation and a mastopexy is the ideal solution for the sagging, small breast, however it is not as simple as it appears.
It is a much more technically demanding procedure than either component on its own. It can be difficult to achieve a pleasing shape and symmetry. There is also the trade-off of additional scarring along vertical lines and around the nipple.

Examples

Fig. 5a
Fig. 5b	Fig. 5c	Fig. 5d

Figures 5: Pre (a) and postoperative (b, c, d) images of a breast augmentation with a 280 cc anatomically shaped cohesive gel silicone implant placed beneath the pectoralis major.

Fig. 6a
Fig. 6b	Fig. 6c	Fig. 6d

Figure 6: Pre(a) and postoperative (b, c, d) images of a breast augmentation using a pre-pectoral implant.

Figure 7: case 1: Pre(above) and postoperative (below) images of a composite breast augmentation, combining breast implants and lipofilling.

Figure 8: case 2: Pre(above) and postoperative (below) images of a composite breast augmentation, combining breast implants and lipofilling.

Figure 9: Pre(above) and postoperative (below) images of an augmentation mastopexy, combining breast implants with a breast lift procedure.

Figure 10: Pre(above) and postoperative (below) images of another case of augmentation-mastopexy, combining breast implants with a breast lift procedure.

What to expect after the surgery

There is usually a dressing applied over the scars. Drains may also have been placed - tubes which come out through the skin to remove any excess fluid. A band, or tape around the breast will hold the implant in place. After these are removed a well-fitting sports bra should be used.
Normal sequelae of the surgery include bruising and swelling. There may be sensory changes to the skin of the chest or the nipple. These are usually temporary. Minor aches and pains after any surgery are to be expected and can be treated with pain killers. If the implant has been placed under the muscle you may be discouraged from moving your arm in certain directions for the first few postoperative days.

Length of Stay

For implants alone or lipofilling you would normally go home the same or the next day. Following a microsurgical procedure you would expect to remain in hospital for three to five days.

After discharge

If the wound has been covered with paper tape, this can be removed by washing after 1 week. Depending on the type of skin closure, you may be given additional advice by your surgeon.

As mentioned earlier, you will need to wear the right support which can be provided by a sports bra. A normal underwired bra can be worn after the first two months. Strenuous exercise and sport should be avoided for at least two weeks and it is better not to sleep on your stomach for the first 8 weeks.

One to four weeks should be taken off work, but daily household tasks can be resumed within the first few days.

Sensory changes experienced immediately after the operation will wear off over time. This will take longer if a larger implant has been used and can rarely be permanent.

Breastfeeding is not affected by breast implants.

Possible complications

Early

• Bleeding
• Infection
• Wound healing problems
• Skin irritation

Late

• Persistent sensory disturbance
• Asymmetry
• Dissatisfaction with volume
• Scar hypertrophy (thickening)
• Persistent pains
• Capsular contraction
• Implant movement, rupture, leak or becoming more palpable
• There is no proven link between breast implants and any systemic diseases. There have been numerous scares in the press, but none have been unequivocally linked.

Final Points

This is a purely cosmetic procedure which your healthcare insurer will not fund. Both the medical costs and fees must be met by the patient. Costs vary from case to case and an agreement will need to be made in advance with your surgeon.

Read more (links)

Read more on the Safety of Silicone Gel-Filled Breast Implants
Read more on breast implant complications
Read more on questions to ask your doctor
Read more about things to consider before getting breast implants