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Procedure: Breast Augmentation

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Breast Augmentation

Breast Augmentation

Breast augmentation is one of the most commonly performed plastic surgery procedures.  In general there are three groups of women who undergo breast augmentation. The first group is characterized by women who feel that their breasts are too small for their body. The second group of women are those whose breasts have “deflated” as a result of pregnancy and breast feeding and the third group of women are truly more reconstructive augmentations as may be performed after breast reconstruction surgery (these women finish their reconstruction with larger breasts than they had prior to their mastectomies). Although breast augmentation can provide a small lift to the breasts as well, when there is more than a moderate amount of breast sagging then the augmentation should be combined with a mastopexy, or breast lift, in order to provide optimal results.

Variable Expectations

Variability exists in the goals of women who are seeking breast augmentation.  Some desire significant outer breast fullness while others disapprove of this look.  Some desire notable cleavage and a very narrow space between the breasts, while others desire more natural spacing.  Some place a priority on size itself and are willing to accept a less natural appearing result. The keys to a satisfactory outcome are realistic expectations and honesty with the surgeon.

Two of the most telltale signs of breast augmentation are an unusually wide space between the breasts and an overly protruding upper half of the breast.  A normal breast shape has a natural slope to the upper half of the breast whereas a rounded, full upper pole is an obvious sign of breast augmentation. On rare occasions some patients desire this full upper pole. Of greatest importance is a careful preoperative consultation to determine the individual desires of the patient. It is up to the surgeon to manage expectations in a realistic manner.

Who is not a Candidate?

A patient who has significant droopiness is not a candidate for breast augmentation alone, and may need a breast lift. Objective measurements as well as subjective criteria can help determine who is a candidate for breast augmentation alone.

Classically, a ptosis (droopiness) scale is used by relating the position of the nipple to the inframammary fold (the fold underneath the breast) when standing upright.

If one were to take a pencil and place it in the fold of the breast one could compare that line with the position of the nipple to determine the degree of ptosis. If the breast looks ptotic in general but yet the nipple is above the inframammary fold, this would be called “pseudo ptosis”, which means false ptosis. Grade I ptosis is noted if the nipple is at the level of the inframammary fold. Grade II ptosis exists if the nipple is below the inframammary fold level when sitting or standing upright. Grade III ptosis would be found when the nipple is not only below the level of the inframammary fold but is at the lowest portion of the breast itself.   Patients with Grade II or III ptosis are not good candidates for breast augmentation in most cases.  Those with grade I ptosis are marginal candidates. The best candidates for breast augmentation are those patients with no ptosis or pseudo ptosis. 

I always coordinate the ptosis grading described above, with other objective breast measurements.  In most patients a line measured from the supra sternal notch (the notch at the top of the chest bone/sternum,) down to the nipple should measure 21 cm or less in most patients. Ideally the distances to the two breasts should represent the equal sides of an isosceles triangle. Ideally the distance from nipple-to-nipple is close to the sternum to nipple length. This is not true in all cases, but is a good guideline to follow.  The most important measurement in my experience that determines the necessity of a breast lift is the nipple-to-inframammary fold distance. This is the distance measured from the nipple to the fold. Ideally this length is 7 cm or less.  If this distance is 8 cm there are modifications of the breast augmentation approach that can be made to avoid a formal breast lift as long as the patient accepts the limitations from such an approach. In my experience, if the nipple-to-inframammary fold distance is greater than 8 cm, especially if there is Grade I ptosis or greater, then a breast lift/skin tightening procedure of some type should be carried out.  It should be noted that a patient with measurements of 8 cm or greater, or greater than Grade I ptosis, typically also have skin that has lost elasticity in the lower pole of the breast. Causes for inadequate elastic fibers include pregnancy, a history of breast-feeding, weight gain, inordinately large breasts, and/or a congenital deficiency. Therefore, even if such a patient chose a large size for breast augmentation, the ptosis problems would not be corrected. In fact, using large implants on such patients would only lead to larger, droopy breasts in the long term. 

Another contraindication to a primary breast augmentation alone would be markedly asymmetrical breasts. Usually when there is such asymmetry, the larger breast needs to be reduced with a breast lift or breast reduction so that the same type and size of implant can be utilized in both breasts. 

 

How is the Procedure Performed?

Planning the Incisions

The most common approaches to breast augmention are via a peri-areolar (around the nipple) approach and an infra-mammary crease (below the breast) approach. The former approach offers the advantage of a well camouflaged incision along the differently pigmented areolar and breast skin as well as good control over the final position of the implant. This approach may not be possible in women with very small areolae. The latter approach provides the most direct access for implant placement, but may leave a more noticeable scar especially if the incision is planned poorly. The transaxillary approach (through the armpit) leaves an inconspicuous scar in the armpit, but has a much greater rate of malpositioned implants. Furthermore, any revisionary surgery must be performed through either an inframammary crease or periareolar incision. Less common approaches which may be performed in select patients are transumbilical (through the belly button) and in combination with a “reverse abdominoplasty”. When breast augmentation is performed in combination with a mastopexy, the incision used will be dictated by the mastopexy approach. Most surgeons prefer placing the implant below the pectoralis (chest) muscle, as this location has been shown to result in a lesser chance of capsular contracture (thick scar tissue formation around the implant)

 

Anesthesia

Breast augmentation is usually performed under general anesthesia, although it may be performed using local nerve blocks in combination with intravenous sedation. The optimal choice of anesthesia will be determined by your surgeon. Studies have shown that placing long acting local anesthetic in the breast at the end of the surgery will reduce the need for post-operative pain medications.

What Can I Expect During my Recovery?

Breast augmentation is performed routinely as an outpatient procedure. The surgery will usually take between 1-2 hours. You may be put into a post-operative bra after surgery, although different surgeons have different post-operative practices.  You will be able to eat and drink normally, likely starting the day after surgery. If your implants were placed below the muscle, you will feel very sore in your chest, as if you have done many push-ups. Decreased sensation or even numbness of the nipple/areola is common in the early post-op period, although this usually returns to pre-operative levels within weeks to months.

How Long Do the Results Last?

There is a common myth that implants need to be removed and replaced every ten years.  I can find no evidence in the literature to support this.  In fact, the re-operation rate of putting someone under general anesthesia is much riskier than maintaining implants that are otherwise causing no problem.  There are many patients who have implants 20-30 years and are continuing to enjoy them without any need for revision.

However, complications can arise, and chief among them is capsular contracture (formation of a scar capsule around the implant). The Baker classification system describes the extent of capsule formation in detail. A Baker I implant is as soft as a natural breast. If it is feels harder than the natural breast and harder than it was on the date of placement, then it is considered a Baker II capsular contracture.  If the breast implant is hard to touch and feel and one can see a disfigurement of the breast, then it is a Baker III capsular contracture. If a Baker III capsular contracture is associated with pain, then it is classified as a Baker IV capsular contracture.  Baker III and IV capsular contractures need to be addressed surgically. The surgical approach involves removal and exchange of the implants after removing the fibrous capsule that is causing the contracture. This fibrous capsule occurs in variable numbers according to literature, but can occur between 15-35% of the time.

What are the Risks?

With any surgery, the major short-term risks are infection and bleeding.  Breast augmentation is a clean procedure done under sterile conditions and therefore the risk of infection is very low.  The incisions tend to heal well, but may widen or hypertrophy. Poorly designed incisions may become visible on the breast or chest wall. A build up of scar tissue around the implant (capsule) may become thick enough to cause pain or even distortion of the implant. Re-operation may be required to remove this scar tissue, reposition asymmetric implants or replace damaged or leaking implants (saline or silicone).

Recovery

The procedure itself takes approximately 30-90 minutes, depending on the difficulty of the procedure. Recovery typically includes 24 to 72 hours of discomfort followed by another week of mild-to-moderate soreness. Though highly variable, return to normal activity can occur within a few days after most breast augmentations.

 

Side Effects and Risks

  • Scarring

  • Capsular contracture

  • Autoimmune disease

  • Cancer

  • Mammography screening difficulties

  • Leakage

  • Deflation

  • Calcification

  • Changes in nipple and breast sensation

  • Rupture

  • Wrinkling

  • Folds

  • Dimpling

  • Infection

  • Excessive bleeding

  • Dissatisfaction with cosmetic result

Summary

Breast augmentation is a commonly performed procedure that provides patients with great satisfaction.  As with all cosmetic procedures, there is some inherent risk and you should choose a surgeon who will spend an appropriate amount of time counseling you with respect to your many choices regarding this type of surgery (implant size, composition of implant, etc) .

References:

  1. Thorne, Charles, et al. Grabb and Smith’s Plastic Surgery, 6th edition.  Philadelphia: Lippincott Williams & Wilkins, 2007.