Lip Teh
January 2006
Breast Augmentation
Introduction
Very high patient satisfaction and has positive effect on self esteem , interpersonal
relationships
Indications
Glandular hypomastia classified as
1) developmental
2) involutional
Pathophysiology
 Developmental hypomastia is a deficiency of skin , sub-cut tissue and glandular
tissue and hormones and genetics play a role in this
 Involutional hypomastia which occurs in postpartum involves a deficiency of
glandular tissue with an excess of skin and sub-cut tissue and glandular ptosis and
pseudoptosis is common
Aesthetic of the breast (Bostwick)
Defines the aesthetics of the breast into two senses
1) tactile
2) visual
1. The attractive and aesthetically pleasing breast is characterized by proper
symmetry, flow, contour and proportion
2. Tactile considerations are softness, smoothness and sensitivity esp. in the NAC
3. Normal volume should range from 300-500g with more fullness lat and inf to the
NA complex and a 45 degree lateral inclination
4. Ideally strong fascial support allows the parenchyma to remain above the IMF
History
 1895 Czerny - transferred a lipoma from the pts back to the chest
 1953 First solid alloplastic materials - polyvinyl ether, PTFE and polyurethane.
Complicated by severe local reactions, pain, hardness and distortion .
 1954 Longacre– used autogenous tissue dermis fat flap to augment the breast with
disappointing results
 1961 Uchida - first report of injectable silicone. Complicated by pain and chronic
inflammation and granulomas
 1962 Cronin and Gerow – introduced subglandular silicone gel, but capsular
contactures were a problem
 1970 Ashley - ”Natural Y” prosthesis a silicone elastomer covered with a
polyurethane foam(PUF) envelope with a silicon gel filler with marked reduction
in contracture rate (1-2%) – later modified to be called the Meme implant
 1991 PUF implants later found to fragment causing foreign body reactions and
possible link to tumourgenesis in animal and thus was withdrawn from the market
 1992 the FDA withdrew the silicone Gel from the market for cosmetic
reconstruction due to concerns about autoimmune disease
 now in the US saline implants are commonly used
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January 2006
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textured implants were introduced and has been shown that the capsular of a
textured in implant is thinner and collagen is less organized when compared with
a smooth and a reduced capsular rate(to baker iii and iv from 21-60 % to 4 %11% in micro-textured implants-Coleman et al
Patient evaluation
History
 Size, symmetry of breasts
 Breast lumps, nipple discharge and infections
 Planning more children, breast feeding
 General medical HX, meds, bleeding disorders allergy,
 Previous breast operations
 Family Hx of breast ca
 self examinations and ecent mammography in age >40
Examination
Breast exam and axilla
 Sit patient up
Note
1. symmetry of breast mound and nipples( ie size, breast location, breast size,
degree of ptosis, nipple location/inversion, inframammary line to nipple
distance and notch to nipple distance)
2. thickness of breast tissue, stretch marks
3. relation of thorax length to trunk(long vs short waisted) shape of the thorax
4. patient height
5. measure chest wall and breast diameter
6. skin evaluated for dermal integrity and stretch marks which are an indication
of compromised skin integrity are noted
7. note presence of tubular breasts
NB asymmetry due to rib flare, chest wall deformities (pectus excavatum, pectus
carinatum, Polands ),postural habitus (scolisois) noted
Non Surgical breast expansion (Khouri PRS 2000)
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January 2006
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brassiere-like system applying 20 mmHg of vacuum pressure to each breast
worn for 10 to 12 hours per day over a 10-week period to obtain an average
increase of 98 percent over starting size.
The stable long-term increase in breast size, however, is 55 percent.
Planning for Surgery
 Traditional method has been to use external filler in bra to estimated size desired
but took no account of effects on breast
 any implant larger than 350 mL induces predictable negative consequences over
time on the tissues of the breast
 After augmentation mammaplasty there is a progressive reduction in breast size
due to breast parenchymal atrophy, skin atrophy and stretching; traction rippling
and costal cartilage remodelling that eventually results in a concave shape of the
ribs.
 Tebbetts in 1994 introduced the biodimensional approach which defined a
patient's desired result by dimensions
o Method - the horizontal and vertical diameter of the existing breast and the
desired projection is factored in and these three values are then entered
into a table to calculate the correct implant size
o Limitations:
(1) defines implant dimensions and volume that force patient tissues to an
arbitrary result defined by patient and surgeon desires instead of
quantitatively characterizing the patient's tissue dimensions and
characteristics, and selecting an implant to fit the requirements and
limitations of the tissues
(2) incorporates no system to limit volume and weight according to patient
tissue characteristics, allowing patients and surgeons to define a desired
result dimensionally and select implants that may be larger or more
projecting than ideal for the patient's tissues, risking potential long-term
negative tissue consequences that can be irreversible
(3) does not specifically address the number one priority in breast
augmentation, that is, ensuring optimal soft-tissue coverage of the implant
long-term
(4) does not address a critical third dimension, tissue stretch, which is a
critical measurement to estimate volume required for optimal envelope fill.
 Tebbetts (PRS Apr 2002) introduced the TEPID system to take into account of
soft tissue characteristics
 T = tissue characteristics of the breast; E = the envelope; P= parenchyma; I
= implant; and D = dimensions and dynamics of the implant relative to the
soft tissues
 Tebbetts (PRS Dec 2005) then developed the High Five Decision Support Process
to focus and simplify the TEPID system
o prioritizes five critical decisions in breast augmentation and enables
surgeons to address all preoperative assessment and operative planning
decisions in breast augmentation in 5 minutes or less.
1. Optimal soft-tissue coverage/pocket location for the implant.
 This determines future risks of visible traction rippling,
visible or palpable implant edges, and possible risks of
excessive stretch or extrusion.
Lip Teh
January 2006
2. Implant volume (weight).
 This determines implant effects on tissues over time, risks
of excessive stretch, excessive thinning, visible or palpable
implant edges, visible traction rippling, ptosis, and
parenchymal atrophy.
3. Implant type, size, and dimensions.
 This determines control over distribution of fill within the
breast; adequacy of envelope fill; and risks of excessive
stretch, excessive thinning, visible or palpable implant
edges, visible traction rippling, ptosis, and parenchymal
atrophy.
4. Optimal location for the inframammary fold based on the width of
the implant selected for augmentation.
 This determines the position of the breast on the chest wall,
the critical aesthetic relationship between breast width and
nipple-to-fold distance, and distribution of fill (especially
upper pole fill).
5. Incision location.
 This determines degree of trauma to adjacent soft tissues,
exposure of implant to endogenous bacteria in the breast
tissue, surgeon visibility and control, potential injury to
adjacent neurovasculature, and potential postoperative
morbidity or tradeoffs.
Soft-Tissue Coverage and Pocket Selection
Options:
1) Prepectoral
2) Subfascial
3) Subpectoral
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Tebbetts believes that umber one priority in aesthetic and reconstructive breast
procedures utilizing any type of breast implant is to ensure optimal (not just
adequate) soft-tissue coverage over all areas of the implant. The potential
consequences of suboptimal coverage are often not apparent to surgeons and
patients for several years following placement of the device (visible traction
rippling and implant edge or shell visibility deformities)
based on quantified soft-tissue coverage to ensure optimal long-term coverage
over the implant
If soft-tissue pinch thickness of the upper pole is less than 2.0 cm, choose a dualplane or partial retropectoral pocket location to ensure optimal soft-tissue
coverage.
If soft-tissue pinch thickness at the inframammary fold is less than 0.5 cm, should
preserve intact pectoralis muscle origins along the inframammary fold for
additional coverage, creating a partial retropectoral pocket (compared with a dualplane pocket in which the surgeon divides pectoralis origins along the fold).
Lip Teh
January 2006
Pre-pectoral/subglandular
 Subgladular best in those with adequate breast tissue to cover the implant
 Indications
1. ptosis and mild excess skin envelope
a. more effectively restore breast shape and correct breast
ptosis than submuscular implants.
2. mild tubular breast
3. active body builders with well developed pectoralis major
 Contraindications
1. irradiated breast
2. avoid in thin breast tissue
3. strong history of breast cancer
 Method:
o Blunt dissection: Blunt dissection in the subgland location prevents
hematoma formation and damage to IMA perforators
o Super pocket (saline implants): Originally pockets the same size of the
implant were created but the result of the forces of wound contraction
further reduced the size of the pocket distorting the implant. Thus now the
pockets are created significantly larger than the implant and maintained as
such by the patient with massaging. Small pocket still for textured
implants.
Subfascial (Graf PRS 2003)
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January 2006
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Advantages:
1. avoids implant deformation or distortion seen in the retromuscular position
2. leaving additional soft tissue support/cover between the implant and the
skin
3. minimizing implant edge prominence inherent to subglandular placement
4. in an animal study, may decrease capsule formation and probably further
capsular contraction (PRS Mar 2005)
May be approached transaxillary, inframammary and periareolar
Tebbetts argues that fascia is thin (0.1-0.5mm) and plane of dissection difficult
Sub muscular ( Dempsey and Latham 1968)
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January 2006
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May be partially behind the pectoralis major muscle (partial retropectoral) or
totally behind pectoralis major and serratus (total submuscular).
Advantages:
1. lowered incidence of clinically apparent capsular contracture
a. Vazquez (Aesth Plast Surg 1987) - 9.4% with the submuscular
approach and 58.0% with subglandular contracture.
b. Biggs (PRS 1990) – 12%(SM) vs 32%(SG)
c. Puckett ((Aesth Plast Surg 1987) – 14%(SM) vs 48%(SG)
2. reduced exposure of the implant to ductal secretions and possible
contamination
3. less vascular plane of dissection
4. maximal preservation of nipple sensation
5. maximises implant concealment
a. improved contour in thin patients as edges of implant blunted
b. enhanced transition from the clavicle to the nipple with the muscle
concealing the superior aspect of the implant
6. makes mammography interpretation easier
Disadvantages
 superior and lateral implant displacement
1. prevent by cutting the muscle at its lower costal and sternal origin
to relieve the pressure on the implant
 distortion of breast shape with pectoralis contraction
 widening the space between breasts
 less control of upper medial fullness
 more postoperative tenderness and more prolonged recovery
 less precise control of inframammary fold position, depth, and
configuration
1. better to sit patient up to adjust fold during procedure
 longer time required for deepening of the inframammary fold
Dual plane (Tebbetts PRS 2001)
 Dual plane = combination of retromammary and partial retropectoral)
 Attempt to avoid a double bubble effect – gravity pulling down breast and
implant being help up by pectoralis
 Advantages:
 glandular ptotic breast with thin soft tissues in the superior pole of the
breast, a partial retropectoral or total submuscular pocket location provides
the necessary additional soft-tissue coverage superiorly but risks a doublebubble deformity resulting from parenchyma sliding inferiorly off the
pectoralis and implant.
 A constricted lower pole breast in a thin patient needs additional coverage
superiorly, but muscle coverage inferiorly restricts optimal expansion of
the constricted lower pole.
 Technique
 selectively dividing the inferior origins of the pectoralis along the
inframammary fold only, with no muscle division along the sternum
 freeing the attachments of parenchyma to muscle at the parenchymamuscle interface by dissecting in the retromammary plane between the
parenchyma and the pectoralis.
Lip Teh
January 2006
Lip Teh
January 2006
Implant Selection
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According to Scales the ideal implant should be
1. impervious to tissue fluid
2. chemically inert
3. non toxic
4. non irritating/non inflammatory
5. non carcinogenic
6. non allergenic
7. resistant to mechanical strain
8. capable of being fabricated to a desired form
9. sterilisable
Lip Teh
January 2006
BRA SIZE
Girth measured under the arms and breast/chest girth measured over the nipple
Increase 1 inch Acup
increase 2 inch B cup
increase 3 inch C cup
increase 4 inch D cup
consider 1 cup size to be about 150 mls or cc, if an implant is under the muscle you
need to allow about 75-100 cc more.
Deciding Size
 Measure the base width of the breast mound as a linear measurement from the
visible medial border of the breast mound to the visible lateral border of the breast
mound in front view.
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Nipple-to-inframammary fold distance (N:IMFMaxSt), measured under maximal
stretch
For optimal long-term coverage, the base width of the implant selected should not
exceed the base width of the patient's existing parenchyma, except in cases of
tubular breasts, severely constricted lower pole breasts, or breasts with a base
width less than 10.5 cm
IMF distance to nipple should be at least 7cm depending on implant size chosen
Deciding on Implant Type
 History
o 1st generation (Dow Corning 1974-1978)
 thick silicone rubber elastomer shell with seams and smooth
surface
 high-molecular-weight “gum” filled with amorphous silica
 Rupture rates were low because of the tough shell,
 complications from high capsular contracture rates and gel-filled
seepage was probably considerable.
o 2nd generation (1979- 1987)
 Smooth surface thin shells
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January 2006
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 Less viscous gels
 Higher rupture and bleed rates
o 3rd generation (1980s)
 increasing the thickness of the outer envelope
 adding an inner barrier layer to limit silicone gel diffusion
 using a thicker silicone gel material which is less likely to migrate
into surrounding tissues should rupture occur.
 Life expectancy not known
Implants can be considered with regards to
1. Shell configuration
2. Filler
Shell configuration
 All breast implants consist of a Silicone elastomer
Shell thickness
 Thick shells are:
1. More resistant to rupture (1st generation=3rd generation>2nd generation)
2. More prone to contracture
3. Less permeable
Seamed vs Seamless
 seamless are more rupture resistant
Outer coating
Polyurethane foam (1970s -1991) – Ashley’s “Natural-Y” prosthesis.
 Advantage:
reduce contracture (<3%) by causing an inflammatory reaction,
microencapsulation of fragmented debris and surface irregularity leading to
multidirectional contractile forces.
 Complications
a) polyurethane coating started disintegrating so that what eventually
remained was a mostly smooth implant surrounded by a capsule containing
foam fragments.
b) Pain, fluid accumulation, and infection were reported.
c) Chronic foreign body reaction
d) Foam fragments made for difficult implant removal
e) Allergic reactions reported.
f) FDA reported in 1992 that breakdown foam (toluene diamine) products
from in vivo hydrolysis may be carcinogenic - estimated lifetime cancer
risk to a human from release of TDA from the cover of a breast implant is
41 per million per implant
Inner coating
 Third generation shells have a barrier layer on the interior surface.
o McGhan’s Intrashiel – diphenyl barrier layer sandwiched between 2 silicone
layers.
o Dow Corning Silastic II – fluorosilicone.
o Reduces bleeding by 90%
 Advantage said to cause less silicone bleeding
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January 2006
Surface texturing
 The reduced contracture rates of polyurethane foam was thought be to due in part
to the texturing
 Microtexturing the surface of an implant by ion-etching was found to modify the
response of the surrounding soft tissues to the implant and retard the development
of an organized, tight collagen capsule.
 Picha confirmed that the collagen in the capsules around rough-textured implants
was less organized and less dense than that of smooth surfaced implants.
 From animal studies, a pore size of 350 μm was required to disrupt the formation
of a continuous capsule aligned parallel to the implant surface
 Probability of contracture increases with time but the textured implants have the
ability to retard capsular development
 The benefit of texturing may be lost if implant placed subpectoral
Collis and Coleman PRS 2000
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Summary of studies (textured vs smooth)
Silicone filled
o Ohlsén 1992 – 0% vs 44% at 1 year
o Malata, Coleman BJPS 1997,2000 – 11% vs 59% at 3 years and 11% vs
65% at 10 years
o Pollock 1993 – 4% vs 21%
o Asplund PRS 1996 – 3-9% vs 10-20% at 1 year, submuscular
o Hakelius PRS 1997
o 25 women, 1 breast smooth and the other textured placed in subglandular
position
o 4% vs 68% at 5 years
Saline filled
o Burkhardt PRS 1994 - 2 vs 40%
o Burkhardt PRS 1995 – 12% vs 22% (lower after Betadine irrigation)
o Tarpila PRS 1997 – 39% vs 38% at 1 year, one type on each side
Inflatable (saline)
 Introduced by Arion in 1965.
 Benefits
1. smaller scar
2. easier to achieve symmetry
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Initial models unreliable
Faulty valve and fold-flaw cracking - defect always in the border between the
patch containing the filling valve and the prosthesis envelope itself.
Most recommend overfilling by 5% to 15%
Underfilling risks: palpable shell folding, visible rippling, sloshing and rupture
Incidence of deflation 0.5-16% (Mentor 1600 ~4%)
1. Risks factors:
 Early – device failure (20% for Heyer Shulte model 1800), damage
during surgery
 Late - underfilling the implant by more than 25 mL, intraluminal
antibiotics, and intraluminal steroids.
Double lumen
 attempt at combining the benefits of saline and gel
 initial design – saline outside ( steroid, antibiotic), gel inside.
 Becker implant – saline inside and gel outside
 Capsular contracture rate – 5%
 Most removed ports within 6 months – some keep it long term
 Benefits:
1. adjustment of the final volume
2. patient participation in the final volume adjustment
3. the ability to offer reinflation should saline sweat through the valve or shell
occur with time
4. treatment of rippling by overinflation
5. in unilateral augmentation, adjustment to match contralateral ptosis by
overinflation and subsequent deflation
6. treatment of early capsular contracture by overinflation and subsequent
deflation
7. mammographic examination of breast tissue is possible by deflating the
implant
 Disadvantages of the technique include the financial cost of the prosthesis,
palpable axillary ports, and displacement or flipping
Anatomical
 Saline and gel forms
 tapered upper pole and fuller lower pole are designed to match the ideal breast
shape, with the more fixed shape designed to prevent upper pole collapse under
gravity ie gravitational forces dictate fluids conform to a teardrop shape.
 given the same fill volume, an anatomic implant with its narrower base will
produce greater projection (24.4%) and greater height (19.6%) than a round
implant.
 Indications (Tebbetts)
1. patients who desire more projection in the lower pole
2. patients who wish maximum size appearance per given volume
3. glandular ptotic breasts
4. constricted lower poles
5. breasts with highly mobile parenchyma likely to slide off the anterior surface
of a round implant and produce the “double bubble” deformity
 Round implants less appropriate for:
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January 2006
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1. thin patients,
2. patients with a high inframammary crease
3. patients with a vertically or horizontally deficient chest
4. ptotic patients.
Advantage
1. In breasts with a tight lower pole - maintain fullness in the lower pole against
the constricting force of the tight skin envelope
Disadvantage
1. patients with wide chest girths - narrower base diameter of the anatomic
implant will not be sufficient to reach the anterior axillary line, and in this
instance a round implant, having a wider base and more volume, may be more
esthetic and achieve the same degree of projection
2. malposition
a. incidence 3-14%
b. more likely with contracture and hematoma
c. make sure snug implant fit into pocket
d. reasons:
i. some textured implants experience no anchoring fibroblastic
ingrowth or collagen deposition
ii. a biofilm or meniscus likely surrounds breast implants, further
discouraging fibroblastic ingrowth, and possibly acting as a
lubricant;
iii. the forces exerted on a retromuscular implant by the pectoralis
major (even more so if the muscle is partially released) are
directed in a horizontal and oblique vector (i.e., clavicle and
midsternal origin to humeral greater tubercle insertion).
Filler
1) Saline
Advantages:
a) lower capsule formation than gel (10-40% vs 36-88%) and contracture rates
(no silicone bleeding). Lower contracture rate independent of implant
placement
a. Gylbert PRS 1990 – smooth gel vs smooth saline 50% vs 16%
contracture
b. Texturing likely to reduce contractures further
b) easier to insert – can be deflated in situ
c) asymmetries easier to correct
d) medications can be added with saline
Disadvantages
a) Deflation
a) Average of 5 percent.
b) Factors affecting rate:
i. Age of implant
ii. Type of implant
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January 2006
iii.
iv.
v.
vi.
b)
c)
d)
e)
underfilling
texturing (less deflation)
capsular contracture
intraluminal antibiotics/steroids/betadine
Sloshing
Unnatural feel – mobile, nonfixed
Propensity for surface irregularities and rippling
Less suitable in subglandular position
2) Silicone
 Silicone is the generic name for a family of silicon-carbon–based polymers.
 regarded as one of the most compatible materials available for implanting into the
human body
 The polymer chains vary in length: the longer the chain, the greater the viscosity
of the silicone.
Advantages
a. Natural feel and look
Disadvantages
a. Bleeding (higher contracture rate)
b. Poorer xray transmission
Cohesive gel silicone vs conventional silicone
Advantages
a) ability to provide a natural and proportionate breast shape
b) easier removal in the event of rupture
c) maintains shape
d) less likely to ripple or fold
e) less likely to bleed
Disadvantages
a) harder feel
b) expensive
c) larger incision
d) only comes in anatomical – more obvious deformity if rotates
e) gel fracture(? significance) – make sure incision is no smaller than 5cm
3) Hydrogel (Polyvinylpyrrolidone)
low molecular weight polymers used in hydrocolloid dressings
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January 2006
Brands
a) PIP - hydroxypropyl cellulose hydrogel gel
b) NovaGold, MistiGold - polyvinylpyrrolidone hydrogel
Developed 1994
Advantages
a) Excreted by kidneys if leaked
b) Provides an excellent lubrication, which in turn reduces the mechanical stress on
the silicone shell = Reduced wrinkling/rupture
c) Good xray transmission
d) Due to the adhesive, sticky consistency of the gel filler = Natural feel
Disadvantage
a) Implant swelling due to cosmetic gradient
a. Misti Gold withdrawn because of this
b. Misti Gold II has a more balanced osmotic gradient
b) expensive
c) insufficient safety details – not approved by FDA
d) ?increased contracture rates – conflicting results
4) Soy Oil (Trilucent)
Advantages
a) clearest xray transmission
Disadvantage
a) Prone to seepage. The adverse reactions consisted of oxidation of the oil, foul
smell, inflammation and swelling, both of which subsided when the implant was
removed. Even though the removal of the implants alleviated the swelling and/or
inflammation, and there was no evidence that they caused long-term health
problems, the implants were withdrawn in 1999.
b) Decrease in volume over time
c) Rupture rate 10%
d) Lumpy capsular contracture
e) ?carcinogenesis from breakdown products – recommended that all Trilucent
implants be removed.
Incisions
1)
2)
3)
4)
Transaxillary +/- endoscopic assisted
Periareolar
Inframammary
Transumbilical
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January 2006
Transaxillary augmentation
 Hoehler 1973 – blunt blind subglandular dissection using urethral sound
 Ideal for those with small breast volume in a high position on the chest
 Can also be placed subfascial and retropectoral
 Endoscope assisted popularized by Tebbets
 Early concerns over limited visibility for dissection, implant malposition, and
insecure hemostasis have faded with mounting experience.
 Use of endoscope has facilitated release of the inferior musculofascial attachments
 Advantage of this technique is that the scar is small and not noticeable and no
incision on the areolar, breast skin or parenchyma
 Disadvantage
o limited exposure
o Subglandular placement if done blindly may be associated with higher
bleeding risk
o Axillary banding – fibrous banding across the axillary scar
o Scar visible if wearing sleeveless shirts
o Increased risk of infection and seroma
o Medial arm (intercostal brachial) numbness – usually transient
o Subclavian vein thrombosis reported
o Implant tends to ride higher
o Unable to address tubular breast or constricted lower pole
o Fails to correct ptotic breast
 Can address pseudoptosis and grade I but is difficult and there are
concerns about over and underdissection
o Limited to round implants although in PRS Aug 2005, anatomical silicone
implants were placed subfascially via endoscope
Technique
Preop
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January 2006
Stand patient, the IMF, midline and the new imf marked(which is usually 1cm below
the existing but varies based on the diameter of the new implant
Operation
Infiltration- care taken to stay parallel to the chest wall
1) 5cm(gel), 3cm(saline) incision in the axillary fold – suture anterior end of
incision to prevent ripping
2) dissection is directed medially to the lat aspect of the pec major muscle.
Then the plane between the pec major and minor is created with blunt
dissection - some use urethral sound)
3) The endoscope is used to assist in the creation of the plane esp for
releasing the infra mammary margin and and cauterizing the vessels
4) Glove washed and the implant then filled with saline or gel implant is used
5) The implant inserted
6) Pt sat up and position checked and pocket adjusted
7) Drain
Post op
 Soft bra (loose)
 No under wire (or tight bra) as it redirects the implant into a superior position
 Oral abs
 R/v at 24 hrs then week to assess for hematomas
 Only those with smooth implants are instructed to massage the breasts
 They are advised to massage in a medial superior and inferior direction but never
in a lateral direction
 by the second week the pt should be able to make the breasts touch one another to
maintain the large pockets and should be sleeping on her stomach to help maintain
the large pocket
Periareolar incision
 Main advantage
1) camouflaged scar on areolar border
2) the ability to dissect the pocket under direct visualization and the ability to
adjust the IMF
3) Ability to perform a limited skin mastopexy
4) Reduce areolar size and glandular scoring (in tubular breasts)
 Disadvantages include
1) Limited exposure for dissecting the pocket
2) Difficulty fitting implant especially if the areolar diameter is less than 3cm
3) Risk of contamination if lactiferous ducts are transacted
4) May interfere with nipple sensation
5) Scarring may be visible on breast mound - beware areolas that are lightly
colored with indistinct margins
 Best used in pts with indistinct IMF and those with large areolars that is not
deeply pigmented
 Pitanguy uses a transareolar incision which leaves a better scar but transects ducts
 Technique
 Pre op markings as above
 A half moon incision made in the areolar side of the areolar skin junction
 Direct incision through breast tissue or subcutaneously down to IMF.
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January 2006
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If the subpectoral implant used the inferior aspect of the pec major is incised
and the pocket created
Closed in layers
Inframammary incision
 Described by Cronin and Gerow
 Most direct route - Allows complete visualization of either the pre- or subpectoral
plane, does not violate breast parenchyma but often leaves an unsightly scar.
 The incision should be placed at or just above the projected new inframammary
fold
 Should measure 3cm for saline and 5cm for gel implants
 May be difficult in those with significant hypoplasia that causes an ill-defined
inframammary fold or with a constricted breast and a breast fold too close to the
areola
Transumbilical
 Described by Johnson 1993
 Subglandular placement, saline implants only
 Subpectoral possible but very difficult
 contraindications
a) the very thin patient,
b) patients with less than 2 cm of pinch test
c) secondary breast augmentation
d) patients with abdominal scars or hernias.
 Disadvantages
a) poor access - provides the worst control for dissection of the pockets
b) unreliable control of the inframammary fold
c) inability to use gel-filled implants,
d) the need for a second incision at the time of revision.
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January 2006
Implant removal
 Removal without replacements show poor results
 Dermoparenchymal mastopexy generally recommended
 Deepithelialized TRAM flap described
Complications
Early
1) Hematoma
2) Seroma
3) Infection
4) Pain
5) Pneumothorax
Late
1)
2)
3)
4)
5)
6)
7)
Asymmetry
Breast pain
Breast tissue atrophy
Scars
Altered sensation of the NAC
Capsular contracture
Implant related
 displacement
 rippling
 noise
 extrusion
 rupture
 calcification
 palpability
 visibility
8) Human adjuvant disease
Hematoma
 0.5-3%
 Pts with hematoma or seroma have a swollen, painful ecchymotic breast that is
tender and firm to palpation
 Early drainage is essential to avoid infection wound breakdown asymemetry or
delayed capsular contracture
 If require implant removed and pocket irrigated with Abs and implant replaced
and ABS post op for a Week
 Seromas are usually localised and non tender and self limiting but may rarely
induce psuedobursa formation
 Hematomas will increase infection and capsular contracture rates(86%)
Pneumothorax
 Risk factor: Subpectoral dissection in thin patients
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January 2006
Seroma
 Generally self limiting
 More common with transaxillary approaches, excessive use of diathermy and
concentrated antibiotic irrigation solutions.
 U/S guided drainage if severe
Infection
 1-2%
 Risk factors: surgical technique, comorbidities, breast reconstruction and implant
replacements, transaxillary/transareolar incisions
 90% positive cultures in nipple – some cover it with adhesive during surgery
 Acute infections usually present 5-14 d post op with warmth swelling and
erythema
 45% may be salvaged by antibiotics although 68% of these will develop
symptomatic capsular contracture
 More serious infections may cause drainage and wound dehiscence. 7 cases of
toxic shock syndrome
 66% are occur early – most due to staph aureus
 late infection like staph epidermidis - chronic low grade periprosthetic infections.
Usually results from secondary bacteraemia.
 Start antibiotics immediately
 if antibiotics don’t resolve the infection implant removed and replaced after a 3
month period
 Removal of the implant may not be necessary, particularly if only skin is
cellulitic or if a periareolar incision was used with initial surgery.
 Implant salvage has been described (Yii PRS Mar 03) following breast
reconstruction by washout, capsulectomy, implant exchange and post-op
continuous saline/antibiotic irrigation. 9 out of 14 patients salvaged.
 Salvage should not be attempted in cases of overwhelming infection or deficient
soft-tissue coverage (Spear PRS 2004)
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January 2006
Pain
 Immediate postop – more likely with subpectoral dissection
 Late pain - most commonly related to contracture
Altered sensation of the NAC
 Inadvertent injury to the 3rd 4th 5th lateral int costal nerves can lead to altered
sensation of the NAC and is as a result of aggressive pocket dissection and
extensive electrocoag at the lateral portion of the pocket- 15 % incidence
 Usually transient
 Reduced risk with submuscular pocket
 Transaxillary can get neurapraxia of the intercostobrachial nerves that usually
resolve
Skin Irritation
 Transient erythema, edema, itching and a burning sensation in the skin of the
breast are peculiar to polyurethane-coated implants and occur in 10% to 20% of
patients.
Galactorrhea
 Rare complication
 transection or irritation of thoracic nerves by the surgery causing prolactin
secretion
 Treat with intercostal nerve block or bromocriptine
Asymmetry
 In the form of volume, projection and lateral or vertical dimension
 High riding implant can be treated with taping
 If over dissection of the IMF taping or under wire used to allow adherence of
the flap
 May develop early (technical issue) or late (tissues stretching or implant
failure)
Capsular contracture
Baker Classification
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January 2006
Baker Class III and IV generally considered as poor outcomes
Histology of capsule

The membrane consists of a thin inner layer of fibrocytes and histiocytes
surrounded by a thick layer of relatively acellular collagen fiber bundles. The
outermost layer is composed of loose connective tissue, whereas the middle layer
is made up of densely packed collagen bundles lying parallel to each other.

Rubino (Ann Plast Surg 2001) described 5 layers in contracted capsules of
textured implants :
 I = inner surface
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January 2006





 II = inner vascular layer (present only in contracted capsules)
 IIIb = intermediate inner layer
 IIIa = intermediate outer layer
 IV = outer vascular layer
 V = outer surface.
Histological differences textured vs smooth implants (Wyatt PRS 1998)
1. Smooth
i. Lining: The capsule adjacent to smooth-surfaced implants is lined with
flattened mesothelial-like cells or contains no lining at all.
ii. Cells: relatively avascular and acellular
iii. Collagen: well-organized bundles of collagen fibers oriented parallel
to the implant surface.
2. Textured
i. Lining: more often lined with synovial-like metaplasia and more likely to
have villous hyperplasia
ii. Cells: A more pronounced foreign body response with increased
amount of foreign material compared to smooth implant
iii. Collagen: multidirectional collagen fiber orientation
presence of synovial-like metaplasia at the lining of capsules in both the smooth
and textured groups decreased with time
presence of a dense, collagenous architecture within smooth capsules increased
with time;
decreased collagen over time with textured implant
Capsular calcification related to the duration of implantation (100% in 20 years) –
unknown significance
Etiology
Remains unknown
Two theories implicate non-infectious stimuli to hypertrophic scar formation
(hematoma, granuloma and hereditary factors) or infectious agents
1. hypertrophic scar hypothesis
 Myofibroblast are seen in the capsule - thought that a chronic low grade
inflammatory foreign body reaction may lead to the release of peptide
growth factor and thus prolong the inflammatory process leading to
hypertrophic scar like formation
2. Infectious hypothesis
 Bacteria exist in two distinct phases, a free-floating or planktonic form and
a sessile form that adheres to solid surfaces by means of a secreted
exopolysaccharide, forming a biofilm.
 This matrix provides protection to bacteria within the biofilm, increasing
their resistance to both disinfectants and antibiotics
 Implicated as a cause of chronic antibiotic-resistant and culturenegative inflammation around implants
 biofilm on the outer surface of the implant, once established, may form a
focus of irritation and chronic inflammation, leading to accelerated
capsular contracture
 Pajkos (PRS 2003) - positive cultures were obtained from either the
capsule or the implant (or both) for 18 of the 19 contracted samples.
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January 2006

Biofilm was demonstrated with scanning electron microscopy in the single
culture-negative sample.
Biofilms are also detected in noncontracted capsules
Incidence
 For saline implants, grade III or IV capsular contracture of 9% at 3 years and
10-11% at 5 years for augmentation patients.
 11% at 10years for textured silicone implants.
Risk Factors
1. Hematoma
2. Infection
3. Reconstructive and secondary procedures
4. Subglandular placement
5. Smooth implant
6. Silicone implant – gel bleed
7. Duration of implantation
Preventing contracture
1. Minimise risk of hematoma
2. Minimise risk of infection
a. Sterile surgical technique – avoid/minimise implant contact with skin
b. Pocket irrigation with betadine
i. Burkhardt PRS 1995 – Betadine irrigation reduces overall incidence of
contracture by 85%
ii. Mentor advises against any contact with saline implant shell as may
increase deflation rate (data actually for intraluminal betadine, other
studies have shown no problems with external irrigation)
iii. Disadvantage: reduces wound tensile strength and is cytotoxic to
fibroblasts (Lineaweaver 1985)
c. Antibiotics
i. Prophylactic benzylpenicillin and dicloxacillin administered
intravenously 1 hour before surgery reduced number of positive
cultures from dissected subglandular pockets from 79% to 7% with
antibiotic prophylaxis
ii. intraluminal (inside implant) Abs have been used with steroids.
iii. Have been shown to reduce capsule but doubles implant failure rates.
iv. Adams PRS 2000 – showed that pocket irrigation with gentamicin
80mg and cephazolin 1gm did not cover Staph Epidermidis but adding
10% povidone-iodine covered it and all other common organisms.
2. Steroids
a. Initially described instilled into pocket with reduction in contracture rate
but concerns rose about wound healing, thinning of skin flaps and
subcutaneous tissue erosion with implant exposure
b. Intraluminal steroids were then shown to have a significant decrease in
capsular contracture
c. Doses of >20mg of methyprednisolone led to 62% incidence of steroid
related complications
3. Cyclosporine A
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January 2006
a. inhibition of the release of interleukin-1, which is a fibroblast proliferation
factor that can be responsible for excessive collagen deposition.
b. when added to the prosthesis shown to reduce capsule formation in rats
4. Mitomycin C
5. Vit E
a. Oral ingestion for antiinflammatory effects
b. Baker prescribes Vit E 1 wk pre op and continues for 2 yrs but unclear of
effects. Rat model vit E shown to delay capsule
6. Expansion exercises
a. For saline implants, Hoeler described technique of forcibly moving
prosthesis within the pocket to maintain the volume of the pocket.
b. More than halves the contracture rate (Vinnik 58% to 28%, Barker 35% to
5%)
Managing the established capsule
Closed compression (Baker PRS 1976)
 Goal is to hydraulically explode the scar capsule without fracturing the
implant- manually squeezing the breast until audible pop heard
 66% success rate but high recurrence rate (80%)
 External ultrasound has been used to prevent recurrence
 Complications (10%) - hematoma, ruptured implant(may be as high as 50 %)
gel migration, dumbbell deformity and incomplete rupture
Open capsulotomy
 Once the capsule is entered it can be scored partially stripped or removed
 recurrence of capsular firmness in 37% to 89% of patients.
 General principle is to perform capsulectomy and change tissue planes if
implant previously infected, otherwise do limited capsulotomy and replace in
the same plane
 Controversial what happens to capsule after removal of implant
 Collis (PRS 2000) found that total capsulectomy for subglandular silicone
breast implant capsular contracture results in a lower capsular recurrence than
anterior disc capsulectomy. The pattern and risk of recurrence after total
capsulectomy and exchange for a modern textured prosthesis appear to
approach those following primary augmentation.
Implant related
Displacement
 Early (technical) or late (steroid use, pectoralis muscle, closed capsulotomy)
 If early treat with taping or external sutures
Noise
 Inadequate air removal or underfilling
Rippling
 Due to underfilling or traction
 Underfilling occurs in saline implants and is seen in the upper pole
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January 2006

Traction is seen in textured implants and due to the implant’s pulling on the skin
where the capsule is adherent to both implant and skin.
Deflation and rupture
Definitions
 Bleed = normal process of diffusion of silicone oil out of semipermeable
silicone shell into capsule
o 3rd generation shells have a fluorinated shell that significantly reduces
bleeding
 Leak = an abnormal condition in which a small amount of silicone gel passes
through a detectable small hole in the shell, resulting in a thin coating of gel,
usually less than 0.5 mm thick, on the external surface of the shell.
 Intracapsular rupture =an abnormal condition in which a major tear or
disruption of the shell occurs such that a significant portion of the silicone gel
lies outside the shell, although still confined within the [periprosthetic]
capsule.
 Extracapsular rupture=displacement of silicone gel from a ruptured implant
through a tear in the [scar] capsule and into the adjacent tissues.
o gel migration, silicone gel granulomas, and chronic disseminated
granulomatous inflammation may result but rarely
Risk factors:
1. underfilling (saline)
2. age of implant
o studies confirm diminishing strength of the silicone shell of breast
implants with duration of implantation.
3. implant type- second-generation implants worst
4. intraluminal betadine, steroids, antibiotics
5. contracture
6. trauma
o closed compression (saline)
o mammography
Rupture Rates
 Most studies for saline implants show 1% deflation/year (7% at 7 years)
 Studies for silicone rupture are confusion as they include old generation
implants
 Metaanalysis of 9770 cases - overall failure rate of 42%, with failure rates of
30% at 5 years, 50% at 10 years, and 70% at 17 years (Marotta 1999)
 12-26% of gel-filled ruptures are extracapsular
 Rates under reported as most are silent and detected at time of mammography
or implant exchange
 Estimated rupture rate 50% at 15 years – they recommended thorough
examination of any presenting implant older than 10 years. (Beekman PRS
1997)
 Rupture rate of modern silicone implant estimated at <10% at 5 years
Diagnosis
 methods
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January 2006
(1) physical examination
a. detecting saline rupture easier than gel rupture
b. Dowden (PRS 1993) squeeze test: identify free-flowing gel within an
implant capsule by squeezing intracapsular free gel through a
constricted portion of the pocket. The test is limited to patients who do
not have contracted capsules. Claims it is more accurate than
mammogram
(2) endoscopic surgical exploration
(3) open surgical exploration
(4) mammography
a. Breast augmentation may interfere with the interpretation of
mammography examinations because implants are radio-opaque
b. limitations – posterior one-fourth to one-third of the implant is
routinely excluded and it primarily assesses morphology of the implant
and therefore cannot detect intracapsular ruptures.
c. Signs of extracapsular implant rupture include a large contour bulge or
opaque axillary nodes containing silicone.
(5) Ultrasonography
a. Sensitivity 70% - reduced by capsular contracture, operator dependant
(6) magnetic resonance imaging (MRI).
a. Most accurate imaging modality
b. Increased sensitivity with use of breast coils (95-100%)
Systemic Disease
1. Tumorigenesis
a. Concern about Oppenheimer effect - any smooth-surfaced material
implanted in the peritoneum of rats will induce sarcomatous changes, but a
roughsurfaced implant will not.
b. Large linkage, case-control and epidemiologic studies have failed to find
an association between implants and breast cancer risk.
c. Silicone gel induced plasma cell tumors noted in mice, but multiple
myeloma not increased
2. Autoimmune disorders
a. Early case reports of associations with progressive systemic sclerosis,
scleroderma, rheumatoid arthritis, lupus erythematosus etc
b. Blood silicone levels are elevated among women with breast implants
compared with age-matched, nonaugmented controls. This is a universal
finding in women with silicone implants and not an indication of implant
leakage. No association between these levels and connective tissue
disease.
 Proposed mech include genetic predisposition with HLA DR-7 and DR-53
genes and conversion of silicone into silica stimulating collagen synthesis
 Institute of Medicine of the National Academies of Science final report in
1999 - there is no definitive evidence linking breast implants to cancer,
immunological diseases, neurological problems, or other systemic diseases.
Women with breast implants are no more likely than other women to develop
these illnesses.
 European Committee on Quality Assurance and Medical Devices in Plastic
Surgery (1998) consensus declaration :
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January 2006

1. Updated studies continue to show that silicone gel-filled implants do not
cause cancer.
2. There are conclusive scientific data that silicone gel-filled breast implants
do not cause any autoimmune or connective tissue diseases.
3. There is no scientific evidence that such things as silicone allergy, silicone
intoxication, atypical disease, or a ‘new silicone disease’ exist.
4. There is a normal foreign-body reaction to every implant, but this is not
immune disease.
5. Silicone implants do not adversely affect pregnancy or breast feeding or
the health of breastfed children.
6. Laboratory tests for the detection of silicone are of no clinical value.
Janowsky (NEJM 2000) – metaanalysis of 20 major studies found no association
between implant and connective tissue or rheumatic disease
Interference with breast cancer detection
 40% of glandular tissue is obscured by the subglandular implant on conventional
mammography (20% for submuscular)
 Both saline and silicone implants show same radiodensities on mammography
 Periprosthetic calcifications do not appear to mimic cancer or increase the chances
of having a false-positive mammogram but calcium deposits may affect the ability
of mammography to detect lesions close to the capsule.
 Eklund’s displacement views indicated for augmented patients.
a. greatly increase the amount of breast tissue that can be seen on
mammogram in the presence of an implant.
b. consists of manually pushing the implant back toward the chest wall
and selectively compressing the breast after pulling it forwards
c. Compared with standard views, which revealed 56% and 75% of breast
tissue in subglandular and submuscular implants respectively, the
Eklund technique successfully imaged 64% and 85% of breast tissue.
 Increased capsular contracture and subglandular placement make viewing harder.
Size of implant is not a factor
 2 recent studies of breast cancer following augmentation mammoplasty suggest
breast cancer diagnosis may be delayed in women with augmentation.
a. Skinner et al (Ann Surg Oncol. 2001) found that mammography was
less sensitive for women with augmentation (N = 99) compared with
women without augmentation (66.3% vs 94.6%) and that women with
augmentation were more likely to be diagnosed with palpable tumors
(83% vs 59%), invasive carcinoma (82% vs 72%), and to have nodal
involvement (48% vs 36%).
b. Brinton et al (Cancer Causes Control. 2000) found women with breast
implants (N = 78) tended to have later-stage disease compared with
women without augmentation (35% vs 17% with regional or distant
disease); however, this difference was not statistically significant.
 General consensus is that augmentation will reduce sensitivity but does not lead to
worse tumor characteristics at diagnosis
 Miglioretti et al (Effect of breast augmentation on the accuracy of mammography
and cancer characteristics JAMA Jan 2004)- Among asymptomatic women, the
sensitivity of screening mammography based on the final assessment was lower in
women with breast augmentation vs women without (45.0% vs 66.8%; P =.008),
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January 2006


and specificity was slightly higher in women with augmentation (97.7%vs 96.7%;
P<.001). Among symptomatic women, both sensitivity and specificity were lower
for women with augmentation compared with women without but these
differences were not significant. Tumors were of similar stage, size, estrogenreceptor status, and nodal status but tended to be lower grade (P =.052) for women
with breast augmentation vs without
Among symptomatic women, women with augmentation had tumors with better
prognostic characteristics, including smaller size, lower grade, and estrogenreceptor positive status. This suggests it may be easier to palpate breast masses in
women with breast implants given their lower native breast volume or because
breast implants provide a firm platform to palpate against. In addition, women
with augmentation may be more breast aware or body conscious and hence seek
medical care more quickly for breast changes or symptoms.
MRI good alternative but low specificity
Mentor Augmentation Patients 3-Year Complication Rates
(submission to FDA)
Augmentation patients experienced the following problems within the first 3 years of receiving
their implants:
21% Wrinkled appearance of the breast
13% Needed another operation
10% Loss of nipple sensation
9%
Capsular contracture (hardening of breast)
8%
Implant removal
7%
Asymmetry (breasts look different from each other)
5%
Intense, painful nipple sensation
5%
Breast pain
3%
Implant leaks/deflates
2%
Implant can be felt
2%
Infection
2%
Sagging
2%
Scarring complications
2%
Hematoma (blood collects around the implant)
Inamed Augmentation Patients 3-Year and 5-Year Complication Rates
Augmentation patients experienced the following complications during the first three years
and first five years after surgery.
3-Year 5-Year
21%
26%
Needed another operation
16%
17%
Breast pain
11%
14%
Wrinkled appearance of breast
10%
12%
Asymmetry (breasts look different from each other)
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9%
12%
Implant can be felt or seen
8%
12%
Implant replacement/removal for any reason
9%
11%
Capsular contracture (hardening of breast)
9%
10%
Intense, painful nipple sensation
8%
10%
Loss of nipple sensation
8%
9%
Implant is in a bad position
7%
8%
Intense skin sensation
6%
7%
Scarring complications
5%
7%
Implant leaks/deflates
3%
3%
Irritation/inflammation
3%
3%
Seroma (watery portion of blood collects around
implant or incision)
2%
2%
Hematoma (blood collects around the implant)
2%
2%
Skin rash
1%
2%
Calcium deposits form around implant
1%
1%
Delayed wound healing
<1%
1%
Infection