Disclosure
The breast has been synonymous with femininity in many cultures almost from the beginning of recorded human history. While preferred breast size varies according to the fashion of the times, increasing or decreasing breast size was not possible in early medical history. However, based on images from antiquity, one can appreciate that breast appearance has been both accentuated and diminished according to fashion over the years. Czerny made the first recorded surgical attempt to enlarge the breast in 1895, when he attempted to transplant a lipoma from the back of an actress to her breasts. The long-term results of this procedure can only be assumed. Gersuny tried paraffin injections in 1889, with disastrous results. In recent history, various creams and medicaments have been used in attempts to increase bust size, and Berson in 1945 and Maliniac in 1950 performed a dermafat flap. Pangman introduced the Ivalon sponge in 1950, and various synthetics were used throughout the 1950s and 1960s, including silicone injections. All of these attempts resulted in long- and short-term disasters. In 1963, Cronin and Gerow developed the first silicone gel breast implant with the Dow Corning Corporation, ushering in the era of reliable breast augmentation. Various types of silicone gel implants were then developed by manufacturers all over the world. Inflatable saline implants and others containing a combination of gel and saline came into use in the 1970s. In 1982, Radovan developed the first generation of temporary tissue expanders for reconstructive uses, and the concept of tissue expansion was born. In 1984, Becker, in conjunction with the Mentor Corporation, developed the first permanent tissue expander designed specifically for the breast, primarily for breast reconstruction after mastectomy. The Becker expander soon found use in breast augmentation in the late 1980s, giving rise to the concept of expansion-augmentation. The use of this implant was curtailed after the implant crisis in 1991, but it was supplanted with the Spectrum implant, which is a permanent saline expander with the Becker valve, fill tube, and reservoir system. While the gel/saline Becker is still available for use (with US Food and Drug Administration restrictions), cost is the primary reason it is unsuitable for use in expansion-augmentation. It has virtually been replaced by the Spectrum saline implant, which has no peer as a combined permanent breast implant and expander.
While breast augmentation is a fairly straightforward and simple procedure, many issues related to size, shape, symmetry, or scarring can lead to unpredictable and undesirable results. In these instances, expansion-augmentation offers a viable and predictable alternative. Size Saline augmentations of the breast have been more common in the United States since the US Food and Drug Administration banned silicone gel implants in 1991. At first, surgeons treated saline augmentations as if they were the same as gel augmentations, but time and experience taught that saline and gel implants behave differently. Some features of the saline implant are superior to those of the gel implant, but the issues of feel, palpability, and rippling seem to mandate that this implant be placed beneath the pectoralis muscle rather than above it. In addition, the texturing on the implant surface, which reduced the gel implant's high rate of fibrous contracture when implanted in the subglandular position, proved to not be an advantage for the saline implant and may even be a contributing factor in implant rupture through fold failure. In the submuscular position, the size of the augmentation can become a deciding factor because of the relatively noncompliant nature of the muscle cover. Depending on the width of the woman's chest, the bulk and strength of the muscle, and the tightness of the overlying breasts and skin, the maximum augmentation could vary from 250-450 mL. Once the maximum fill volume is obtained in a submuscular augmentation, the breasts assume a spherical shape and become firmer than a realistic breast, thus limiting the aesthetic result. This problem can be compounded when performing a secondary augmentation (ie, switching from a subglandular pocket to a submuscular one because of scar tissue [fibrous capsule] overlying the pectoralis muscle). The concept of tissue expansion is that as tissue is gradually stretched, it accommodates. If the tissue is stretched beyond a certain end point for a period of time and then the stretching force is reduced, redundancy results. This concept is used in the expansion-augmentation technique. Implants are placed at surgery in the same fashion as any saline implant except that the microreservoir is attached to the fill tube and is implanted under the skin. The size required to achieve the desired result is decided preoperatively. The implant is initially filled at surgery to a comfortable size, and weekly expansions of 60-120 mL are performed, beginning after the first postoperative week. The reservoir is placed near the incision for easy removal later, without an additional scar. After the decision has been made preoperatively that a certain size is required to achieve the desired result, the expansion is performed first to the desired size, then beyond that size for a period. The excess fluid is then drawn out of the implant, creating the redundancy, which is expressed in the shape and softness of the resulting breast. The reservoirs are usually removed shortly after completing the expansion process, with the patient under local anesthesia, but Berrino leaves the reservoirs in for an extended period for later adjustment of fluid volume. With the patient under local anesthesia, the removal can be performed in the treatment room or operating room through the prior incision, thus preventing the creation of a new scar. Using this slow stretching of the breast, submuscular breast augmentation has virtually no size limitations. Additionally, with this technique, the patient becomes an active participant in the outcome of her own breast augmentation and ultimately will be happier with the result. Shape The shape of the breast during an expansion-augmentation can be affected by the amount of redundancy created. Usually, shape is titrated with softness. The softer the resulting breast, the more natural it looks and the more like a real breast of a similar size it becomes. The firmer the breast, the rounder it appears. This titration occurs at the end of the process when the excessive fluid is removed. It can be affected by the ultimate size of the implant versus the manufacturer's recommended size (ie, if the final size is larger than the recommended final fill volume, the implant will naturally be more spherical). Further, it can be affected by the final volume obtained versus the amount of fluid removed, even within the manufacturer's recommendations. The author prefers to remove no less than 100 mL and no more than 200 mL, and it is within this envelope that the titration of shape occurs. Symmetry The expansion technique is used with greatest success in overcoming breast asymmetries, which can range from simple volumetric differences to much more complex issues involving volume, nipple position, implant base width, and ptosis or pseudoptosis. The artistic usage of an expandable implant can result in much greater breast symmetry, even in very difficult cases, without resorting to unilateral mastopexies or nipple lift procedures, which, in themselves, destroy symmetry. If the breast with the higher nipple is overexpanded to a greater volume and for a longer time than the breast with the lower nipple, after release of the fluid, that nipple will fall farther than the other, often creating greater symmetry. This fall is quite striking if the expansion occurs in the subglandular space on the affected side, but some descent is also possible in the submuscular position. Other asymmetries can also be “stretched out,” and these include differences in roundness, inframammary crease position, size, and shape. Scarring The shape of the breast can be adversely affected by prior scar tissue from any number of causes, with fibrous encapsulation as the most frequent cause. A well-known phenomenon is that persistent stretching overcomes scar tissue and changes tissue shape. In the breast, scar tissue can limit the roundness of contour, which is considered an attractive trait. Expansion can restore proper shape to breasts that have become misshapen because of scarring. Further, if the problem is repeated fibrous encapsulation, overexpansion for a longer period, sufficient to obtain mature scar tissue, can overcome a recalcitrant fibrous capsule. The tuberous breast and pseudoptotic breast have an abnormally high inframammary crease that can result in a double-bubble effect if one simply places a submuscular implant below the natural inframammary crease. Expansion can also overcome this problem. Another extremely useful feature of the expander is for the treatment of capsular asymmetries created by prior breast implant surgery. When performing an internal capsulodesis with a running or interrupted suture technique, the expander can be placed into the pocket greatly underinflated to avoid putting tension on the repair. The implant can remain underinflated for 3 weeks to allow for wound healing, and then it can be filled. Overfilling then overcomes slight irregularities in the contour that may have been created by the internal capsulodesis. Mastopexy-augmentation Often, using an implant with a mastopexy or with a breast reduction becomes necessary and desirable in order to achieve an optimal result regarding long-term breast shape. However, many plastic surgeons have experienced that the 2 procedures (ie, mastopexy and augmentation) are often at odds with each other. Performing the 2 procedures simultaneously can cause an increase in complications such as nipple-areola complex pedicle necrosis, implant dehiscence, and implant malposition. In some cases, the size of the chosen implant proves too large to permit proper wound closure. The postoperatively adjustable feature of the expandable implant makes the combination procedure both safer and better. The same mastopexy technique normally chosen by the surgeon is used. The implant is placed into a totally submuscular pocket, which is closed with the fill tube externalized through the wound in the muscle. The author usually temporarily fills the implant to 300 mL and then performs the necessary glandular shaping inherent in the chosen mastopexy technique. The author then reduces the volume as needed to obtain a tension-free closure. The fill tube is cut, and the microreservoir is attached and placed into a subcutaneous pocket medial to the vertical incision. Postoperatively, it is filled in stages to the desired volume. Overfilling and releasing fluid, as described above in the expansion-augmentation technique, is not usually necessary.
Please see the photograph series at the end of the article. The series illustrate the results obtainable with the expansion-augmentation technique and the Spectrum implant for mastopexy and augmentation. With expansion, extremely large breasts can be created, if requested, because the manufacturer's recommended volume can be exceeded. In addition, always expect the patient to request a larger volume at the end than in the beginning. The patient in Image 13 requested a 2-cup increase, and the estimate was for a total of 850 mL, with a smaller implant to achieve greater roundness. The final volume was 1130 mL. |
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Images 1-2 reveal that from 1993-1999, the author performed breast augmentations on 480 patients (960 implants). Of these, 131 were expander patients (262 implants) and 349 were standard implant patients (698 implants). The complications studied were deflation, infections, capsular contracture, and reservoir extrusions. Deflation Overall, deflation occurred in 21 (2.1%) of 960 implants. For standard implants, deflation occurred in 13 (1.86%) of 698 implants over this 5-year period. For expanders, deflation occurred in 8 (3.05%) of 262 implants. Infections Overall, infections occurred in 6 (0.63%) of 960 implants. For standard implants, infections occurred in 5 (0.52%) of 960 implants. For expanders, infections occurred in 1 (0.1%) of 960 implants. Capsular contractions A total of 25 of the 960 implants had a Baker rating of higher than 2, yielding an overall rate of 2.6%. Of these, 15 of 698 were standard implants, yielding a rate of 2.1%. Ten of 262 were expanders, yielding a rate of 3.8%. The slightly higher rate for expanders can be partially attributed to the patient's desire to sacrifice size for softness. Reservoir extrusions This occurred in 2 (0.76%) of 262 expander implants.
The expansion-augmentation technique is a useful adjunct to breast augmentation and mastopexy-augmentation in selected patients and should be considered a part of every plastic surgeon's armamentarium. In difficult cases involving implant malposition, recurring fibrous capsular contracture, or asymmetry of volume or breast shape, these implants can make a very difficult case almost simple. Patients accept this technique readily and are uniformly happy with the results; they typically are especially happy to be a part of the size-related decision-making process.
Uses of the Postoperatively Adjustable Implant in Aesthetic Breast Surgery excerpt | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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