Breast Augmentation Options & Procedures

This article was kindly contributed by: Roger J. Friedman, M.D. and Douglas L. Forman, M.D of The Plastic Surgery Institute of Washington. There are three incisions through which a breast implant can be placed. They include the armpit or transaxillary approach, the edge of the nipple or periareolar and in the fold beneath the breast or inframammary. This may be a personal preference issue of the patient or physician or based on the shape of the breast. If a patient has a distinct fold and a normal size nipple, greater than three centimeters in diameter, she may use any of the three approaches. If the patient has no distinct fold and a normal size nipple the preferable incision is periareolar. If the patient has a small nipple and no distinct fold or wants to completely hide the scar the transaxillary approach is preferable. There are some physicians who offer the trans umbilical approach, through the edge of the navel, but there are some drawbacks to this approach. It is very difficult if possible to place an implant under the muscle from this approach and to our knowledge the manufacturers will not warranty their implants when inserted in this manner.

The inframammary incision is placed just above the fold beneath the breast such that if a patient is wearing a two piece bathing suit and the suit rides up, the scar is not exposed. This approach provides the opportunity to develop the pocket without cutting through the breast tissue as the incision is just at the edge of the breast tissue.

The periareolar incision is placed on the edge of the nipple at the junction of the pigmented skin of the areola and the lighter skin of the breast. From this approach dissection can proceed directly through the breast tissue or tunnel parallel to the skin down to the fold and then under the breast tissue and muscle at the level of the fold. This provides the best approach to release a tubular or constricted inferior pole breast deformity.

The transaxillary approach hides the incision in a natural crease in the armpit. To best develop the pocket, endoscopic techniques are utilized. The only down side to this approach is the fact that if bleeding is encountered at the lowest point in the pocket and it cannot be controlled from the armpit approach, the patient may require an additional incision in the fold. This is extremely rare and has not happened in my personal experience. This approach also takes a little longer than the other 2.

There are 2 alternatives for the location of the pocket for the breast implant, sub pectoral and sub glandular. Some people will use the term, retro pectoral or under the muscle and retro glandular or over the muscle. Personally, we feel that saline implants placed behind the glandular tissue, on top of the muscle, have the potential for more visible rippling. Also the natural slope of the breast maybe more distorted. When placed under the pectoralis major, the pressure of the muscle helps to smooth out the implant helping to minimize the appearance of rippling. Under the muscle the breast has a very natural slope in profile.

There are advantages and disadvantages of both locations. Any one who gets an implant gets a capsule. This is a normal phenomenon. It is your body's way of saying, "this implant is not part of me and builds a wall of scar tissue around it." Five to eight percent of patients develop a capsular contracture. This is when the scar tissue capsule tightens around the implant creating firmness, possibly distortion, possibly discomfort. We feel this is lessened by irrigating the pocket with an antibacterial solution, placing the implant under the pectoralis major muscle and manipulating the implant around the pocket in the post operative period to maintain the pocket larger than the implant. In the sub pectoral position, when the muscle contracts, the implant may move. This is less evident under the breast tissue.

When implants are placed in either pocket, there is some loss of information in mammography as the implant compresses the breast tissue making it appear denser. In the sub glandular position, the breast tissue wraps around the implant and peripheral information is more difficult to obtain. In the sub pectoral position, there is a layer of muscle separating the implant from the breast tissue with the exception of the lowest portion of the implant, near the fold where the implant is in contact with the breast tissue due to the shape and contour of the muscle. Additional views are required for the most information in implant patients. These are called Ecklund or pushback views. The purpose is to pull the breast tissue away from the implant to get a better visualization of the breast tissue. There are 3 companies whose implants I have used. They include: Mentor, McGhan and Pip. All are saline filled. The only difference is the Pip implant, which is a prefilled saline implant as opposed to the other two, which are filled at the time of surgery. Implants may have textured or smooth surfaces. Initially, the implants were smooth. Textured surfaces were then developed with the thought that they would lessen the incidence of capsular contracture. This has not really been proven. What is evident is that patients may appreciate more rippling in the skin surface when textured implants are placed and this may be more noticeable with heavier texturing. Implants may also be round or teardrop. The concern with teardrop implants is that they may shift or rotate. If this happens they then may look distorted especially if only one shifts. Therefore, our preference is smooth round implants. If they rotate, they are always round. Saline implants for lack of a better description are balloons. They have a three- percent failure rate. All implants will eventually fail. The manufacturers warranty the implants. When this occurs, the manufacturer will replace the implant but not cover the hospital costs with the exception of the PIP implant which is now offering money toward hospital costs. First time augmentation patients are only eligible for saline implants. If a patient has had a previous augmentation and are now getting a larger implant or revision, or a patient who is having a breast lift termed, mastopexy, in conjunction with an augmentation, they are then eligible for silicone gel implants. There was a soy bean implant that was being studied but, has recently been taken off the market in Great Britain. The purpose of the consult is for the physician and patient to meet. This sounds quite obvious but, the real question is whether the physician and patient are on the same wavelength. There are several questions the patient must ask herself. Do you as the patient feel the physician has presented the material clearly and confidently, are your questions answered and do you feel this physician can attain your goal and expectations?

Initially, a history is taken with emphasis related to the breasts. The patient is asked what their concerns are regarding their breasts and what their expectation is of the surgery. The procedure, hospital experience, postoperative course and associated risks and complications reviewed. Patient examples are shown and the patient is shown the actual implant alternatives.

The patient is then examined, measurements are taken to assist in assessing symmetry and the breasts are examined to ascertain if there are any masses in the breasts. If any are identified, a mammogram will be ordered and this will be pursued prior to surgery. Photographs are taken and reviewed with the patient.

At this point the patient is placed in a bra consistent with the size she would like to be. Gel implant sizers are then placed inside the bra and the patient placed in a T-shirt to assist in determining the best size. The key is how you look not the cup size. This maneuver helps the patient to better conceptualize but it does not show the change in cleavage that the patient will achieve. There is no way to show this as the sizers are placed on top of the breast and the actual implant is under the tissues.

The procedure can be performed in an office operating room or the hospital. The procedure takes 1.5  to 2 hours. Anesthesia can be either general anesthetic or axillary block with supplemental intravenous sedation. During the operation the patient is positioned with their hands on their hips to minimize distortion of the breasts as can occur if the arms are out to the sides. Once the implants have been placed in the pocket, the patient is brought to an upright sitting position while you are asleep to assess the symmetry, and fold location. At the completion of the procedure, the patients are often given intercostal nerve blocks to minimize their postoperative discomfort. These last approximately eight to ten hours. The DRESSING consists of padding and ace bandages wrapped circumferentially as a "tube top." The patient is then taken to the recovery room where they will spend the next hour and then discharged home. PRESCRIPTIONS are provided for infection prevention (antibiotics), pain control, muscle relaxation, and nausea. The most common complaint is that of pressure. "It feels like you are sitting on my chest." This is because the dressing is intentionally tight and the fact that the implants are placed under the muscle which still thinks it lives on top of the rib cage and is trying to flatten out the implant. This is a muscle spasm. To minimize this sensation, the patient can take a muscle relaxant and as they are lying flat on their back in bed, a folded towel can be placed under each shoulder so that you are sleeping round-shouldered which takes tension off the muscle. This dressing is left in place for two to four days. At that time the dressing is removed and the patient placed into a bra. Our preference is a Warner Bra style 1046 or 1058 or something similar. This bra is comfortable and supportive. It does not have an underwire or a defined cup therefore; it contours to your breast. Patients are asked to wear this bra for the next month during the day only unless they prefer to wear it at night as well. SUTURES are tunneled under the surface of the skin, like a hem, and are absorbable. Therefore they do not require removal. Upper body activity is limited for two weeks. Specifically, you can do what ever you want with your arms as long as your elbows remain by your side. At two weeks, you can start using your arms more freely, gradually returning to your normal level of exercise. Often patients will awaken in the morning feeling very tight. Do not stretch! Get into the shower, the warm water from the shower will allow your muscles to relax. Then stretch gradually. The expectation is that at 2 weeks the patient gradually starts to resume their normal level of activity and are at 100% at 3 to 4 weeks. These are exercises that are initiated approximately one and one half weeks after surgery. The purpose of these exercises is to manipulate the implant around the pocket maintaining the limits of the pocket larger than the implant. This we feel helps to minimize the incidence of capsular contracture. Exercises are performed morning and evening, one time on each side, forever.

The exercises are performed using the left hand for the right breast and vice versa. The exercises are performed in three directions. The little finger is placed in the fold beneath the breast with your hand resting on the breast. Without lifting your hand, the breast is compressed which moves the implant to the upper part of the pocket. The hand then releases and the breast drops down. The hand then reaches around to the outside of the breast and gently pulls the breast toward the center of your chest, the sternal bone. Lastly, pushing from the inside of the breast outward. This moves the implant to the outside limits of the pocket.

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