Disclosure
Breast surgery is performed to enhance the size and shape of a woman's breasts. Surgery typically improves the individual's self-image. Historically, breast enlargement was accomplished by 1 of 3 methods, with varying results of success.
Implants have been used since the 1960s to enhance and enlarge the shape of female breast tissue. Currently, they are the preferred approach for augmentation mammaplasty. First used in 1964, when reported by Cronin and Gerow, silicone still is used for augmentation of female breasts. The advantages of silicone-filled implants include minimum solubility of the silicone and excellent viscosity of the material, providing an excellent feel to the breasts. Problems associated with silicone implants include capsular contracture, granulomas that develop following leaching of silicone from the implant, and migration of silicone into the axilla. Autoimmune responses have been reported regarding silicone implants in breast augmentation. These were discredited because of a number of exhaustive long-term studies that failed to demonstrate increased incidence of long-term problems in large numbers of women who underwent augmentation with silicone implants. When the Food and Drug Administration (FDA) temporarily removed silicone implants because of purported increased incidence of autoimmune phenomena, a considerable amount of interest arose regarding the use of saline implants to augment breast tissue. Saline-filled implants have been used since the 1960s. Saline is absorbed safely into the bloodstream if a loss in the integrity of the implant capsule develops. Saline commonly is used in intravenous (IV) solutions and poses no risk to patients. Saline implants purportedly have a decreased capsular contracture rate when compared with silicone implants. However, saline has slightly decreased viscosity compared to silicone. The initial use of saline implants resulted in a high incidence of deflation (approximately 10%). Over the last 10 years, significant work by implant manufacturers to improve the integrity of implants and specifically to improve the reliability of the valvular mechanism for introduction of saline into the implant has resulted in deflation rates that are predicted to be less than 1%. After having been removed from general use by the FDA, silicone implants have been exhaustively studied and have been shown to have low complication rates comparable with or, in some cases, lower than those of saline implants. The FDA subcommittee on silicone implants has recommended that silicone implants be reintroduced in the United States. Silicone implants were never removed from the European market. History of the Procedure: Implants may be either round or teardrop shaped. Round implants are disc shaped and exhibit equal fullness in all 4 quadrants of the breast (see Image 1). Teardrop or anatomic implants exhibit reduced augmentation fullness in the upper pole of the breast with increased fullness in the lower half of the breast (see Image 2). These implants also are narrower at the superior and inferior poles than rounded implants. The implant capsule may be smooth or textured. Textured implants initially were developed as an alternative to polyurethane-covered silicone gel implants, which first were introduced in the early 1970s. Initial reports indicated polyurethane-covered silicone gel implants resulted in decreased capsule formation. Ingrowth of scar tissue into the polyurethane surface was postulated to break up the vector forces of scar contracture. Because of the altered vectors of scar contracture, the capsule of the scar was unable to contract to the same degree as typically present around a silicone implant; however, this theory never was proven definitively in a scientific study. However, it became clear that polyurethane underwent microfragmentation and phagocytosis. In addition, the polyurethane possibly would break down and dissolve within the tissue locally after placement of these implants. An intense foreign-body reaction with numerous macrophages and multinucleated giant cells occurred in the capsule in some patients who had this type of implant. Because of these problems, implants with a polyurethane-covered coat were removed from the market. The implant manufacturers, in an attempt to duplicate the potentially protective value with regard to capsular contracture in polyurethane-covered silicone gel implants, sought to increase the wall of standard saline implants to duplicate the effect noted with polyurethane. This same approach also was attempted in silicone implants. Unfortunately, results from increasing the capsular thickness with surface texturing have not conclusively decreased capsular contractures in patients undergoing breast augmentation. Reports of increased wrinkling because of placement of textured implants in individuals undergoing breast augmentation have been noted.
Contraindications: Severe ptosis is a relative contraindication to surgery. Women with significant ptosis may require a mastopexy concomitantly or as a secondary procedure. Women with tubular breasts also are at significant risk of secondary procedures after the augmentation to correct residual deformities secondary to the original tubular shape of the breast. Evaluate severe associated medical conditions on a patient-by-patient basis, as with any surgery.
Surgical therapy: Placement routeImplants may be placed by a number of routes that typically vary with surgeon preference and experience. The individual's desired results may influence the site of implant placement. Inframammary approach An inframammary incision is the most common approach for placement of a breast implant. This approach, which entails a 3- to 4-cm incision, attempts to place the incision in or adjacent to the inframammary crease. The inframammary approach provides the most direct route and, in general, requires the least operative time for placement of the implant. Problems associated with inframammary incisions include a visible scar on the anterior surface of the breast. Additional problems center around the difficulty in placing the incision in the inframammary crease, which potentially is exacerbated with low-profile implants. Periareolar approach Implants placed by an incision within the pigmented areolar tissue, referred to as a periareolar incision, often result in the least conspicuous scar. However, dissection of the pocket required for implant placement is more difficult with a periareolar incision. Dissection must proceed through a portion of the breast tissue or in the subcutaneous plane. Problems with subcutaneous dissection include nodularity and inflammation. Incisions placed through the breast tissue or in the subcutaneous plane are associated with microcalcification and cyst formation. Medial placement of the periareolar implant incision within the areolar avoids the fourth intercostal nerve, which supplies sensation to the nipple and areola. Transaxillary approach Placing incisions in the axilla, referred to as a transaxillary approach, avoids placement of the scar on the breast. The transaxillary approach provides the worst exposure for placement of the implant, which is a disadvantage. This may be avoided using special instrumentation, including endoscopes and specific surgical instrumentation designed to aid the dissection. An increased incidence of paresthesia involving the nipple-areolar complex exists with this approach. Obtaining symmetric pockets is more difficult, and damage to the intercostal brachial nerve and subclavian venous thrombosis has been reported with this technique. Additionally, if infection results, removal of the implant may require conversion of the transaxillary incision to one of the other incisions listed above. Hypertrophic scar formation also can occur in the axilla, and the incision may be visible when the patient wears a sleeveless dress and elevates her arms. Periumbilical approach A periumbilical approach, involving placement through the umbilicus, can be used for augmentation of the female breast. Placement of the implant is restricted to a prepectoral plane, and this approach provides the worst control for dissection of the pockets. Superior dissection and symmetry of placement are difficult, even in the most experienced hands. Complications of hematoma or infection require conversion to one of the other incisions for implant removal. Additionally, placement of saline-filled implants through a periumbilical approach requires a special type of valvular mechanism, and long-term reliability of the valvular mechanism in these implants has not been fully clarified, at least to the author's satisfaction. Implant placementImplants may be placed directly beneath the mammary gland or in a plane below the pectoralis major muscle. Advantages attributed to placement below the gland include ease of dissection, predictable sizing and contouring, and satisfactory results provided capsular contracture does not occur. Placement of larger implants in a subglandular position than in a submuscular position is also feasible (see Image 3). Submuscular placement of implants was developed in response to problems associated with subglandular placement, specifically, capsular contracture and visibility of the edge of the implant (see Image 4). Additional benefits attributed to submuscular placement include reduced sensory changes in the nipple, decreased rates of capsular contracture, and ease of interpretation of mammographic studies. The submuscular plane is avascular, and incidence of hematoma may be reduced by placement in the submuscular plane. Disadvantages include potential limitations on the size of the implant, increased postoperative pain, and the possibility of lateral displacement of the implant. In addition, obtaining significant cleavage is more difficult with submuscular placement. If significant cleavage is desired, detach the inferior portion of the pectoralis musculature from its sternal attachments (see Image 5). This results in increased postoperative discomfort. |
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Hematoma The frequency of hematomas is less than 2%. Associated symptoms of hematoma typically are unilateral pain, swelling, and occasionally fever. Hematomas may develop slowly without symptoms or rapidly with symptoms. Small hematomas may resolve without intervention, but large hematomas require drainage. Often, delaying drainage until liquefaction of the clot has occurred is preferable. However, if the hematoma is painful or large, drain it immediately. Infection Incidence of infection is approximately 2%. Infection typically becomes apparent 7-10 days postoperatively but may manifest at any point. Typical presenting symptoms of infection include swelling, discomfort, pain, drainage, and cellulitis overlying the breast. Typically, drain and irrigate the wound. Removal of the implant may not be necessary, particularly if a periareolar incision was used with initial surgery. Prescribe antibiotics immediately. If the implant is not removed, infection may result in severe capsular contracture. If the implant is removed following infection, it typically is replaced in 3-6 months. Staphylococcus epidermidis or Staphylococcus aureus commonly may cause infections. Sensory changes Changes in nipple-areolar sensation are common postoperatively in patients who have undergone breast augmentation. Most patients exhibit a temporary dysesthesia, which tends to resolve in a period of months. However, a small percentage of individuals may present with long-term sensory changes in one or both nipples following breast augmentation. An increased incidence of sensory changes is noted with transaxillary augmentation, since this approach directly crosses the fourth intercostal nerve, which supplies sensation to the nipple-areolar area. Scars Hypertrophic or keloid scar formation is uncommon following breast augmentation. The lowest incidence of hypertrophic scarring appears in periareolar incisions. The presence of a hypertrophic scar in inframammary or axillary incisions may require re-excision and closure of the incision. Asymmetry Asymmetry of the implant position may result from shifting of the implant, increased contraction of the capsule unilaterally, or ptosis of the implant, which is attributed to placement of steroids in the pocket and/or breast prosthesis. Contour irregularity and implant extrusion Contour irregularity and implant extrusion also are rare events that may be associated with the placement of implants. The most common cause of contour irregularity is a tight capsular contracture that may develop around the implant. A wide range of incidence of capsular contracture, from 0-74% of patients, has been noted following breast implantation. The incidence of capsular contracture appears to be approximately 30% of individuals who have undergone the procedure. Classification of the contracture is highly subjective. In 1980, Little and Baker developed a classification for the capsular contracture present in patients following breast augmentation, which remains the standard for evaluating this complication in patients. The grades of capsular contracture are divided into 4 types:
Subclinical infection may cause capsular contracture, with S epidermidis the most probable etiologic agent. Various techniques, including massage, which expands the size of the capsule, attempt to reduce the incidence of this complication. The role of antibiotics in the prevention of capsular contracture is unclear. Antibiotics may benefit if subclinical infection is a factor. However, in patients in whom this is not a problem, antibiotics provide no benefit to the individual. Capsule formation may require surgical capsulotomy, which involves circumferential and radial division of the capsule. In addition, the extent of the pocket is increased. Recurrence following capsulotomy approaches 30%. Complications of capsulotomy include bleeding, infection, and implant exposure. In addition, contour irregularities may arise because of rippling of the implant. Individuals with thin skin are more susceptible to this problem. Silicone implants seem to be subject to less rippling, but they are currently available for this problem only with investigators in an approved protocol by the manufacturer. Medicolegal pitfalls Medicolegal pitfalls typically are concerned with informed consent. Discuss previously enumerated complications preoperatively. Recently, the Food and Drug Administration approved saline implants, but not for use in minors or via a periumbilical approach.
Despite the extensive list of potential complications, breast augmentation remains one of the safest and most predictable procedures performed. The low incidence of complications and the predictability of surgical outcome have prompted an increasing number of individuals, who currently are dissatisfied with their breasts, to undergo the procedure. The surgery provides a balance between the size and shape of the individual's breast and overall body size and shape.
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