Implant type

A significant consideration when planning augmentation mammaplasty is whether to utilize silicone or saline implants. Both types may be used to produce excellent results, with each possessing its merits and potential drawbacks.

The silicone implant resembles breast tissue to a greater extent, creating a more natural appearance and feel. This is often of primary consideration to the patient, and is reflected in the increased use of silicone since FDA reapproval. However, in view of the fact that the implants are pre-filled, they necessitate a somewhat larger incision. This is generally no more than a 1–2 cm variance, but is of course dependant upon implant size. Additionally, many women are still apprehensive about the perceived health risks associated with silicone. Despite the validation of safety regarding systemic autoimmune disease, the local inflammatory responses to free silicone from extracapsular rupture can produce cosmetic issues that may be challenging to manage. However, this has become much less of an issue in recent years with the additional barrier layer of the third generation silicone implants, and increased cross linking of the silicone for a more cohesive gel.

From 1992 to 2006, saline implants were the only prostheses available for use in the United States except for clinical trials, and operative techniques therefore advanced. Remote incisions such as those used in the transaxillary endoscopic approach have evolved with the use of saline implants, and become more popular during the time period of the silicone moratorium. A demographic of surgeons trained in laparoscopy also naturally contributed to this evolution. Implants can be placed through a relatively small incision, and this option allows the surgeon to intraoperatively adjust fill volumes to more readily correct asymmetries. They are also less costly than their gel counterparts, and are regarded by some to provide for more natural movement with activity. Saline implants are, on the other hand, more prone to rippling as well as spontaneous deflation. Regardless of implant type, proper selection must be a joint process between patient and surgeon. A biodimensional approach using the measurements of at the very least base diameter, tissue pinch, and nipple to inframammary fold discrepancies should be employed and are to be covered in another chapter of this text.

Placement

The breast pocket may be created in either the subglandular or subpectoral space (Fig. 53.1). The subglandular technique is usually reserved for patients who have substantial breast tissue or a mild degree of ptosis, since greater projection may be obtained. Also, women who are avid bodybuilders may prefer subglandular implants for the reason that placing them submuscularly, in some instances, may produce breast animation and distortion when the pectoral muscles are flexed. Increased risks of capsular contracture, rippling and implant palpability are typically issues discouraging the routine use of the subglandular plane.

Fig. 53.1 Subglandular vs. submuscular figure depicting subglandular versus submuscular placement. Note the inferior of the implant is covered by breast gland and fascia, and the top by pectoralis major muscle.

In patients with a paucity of breast tissue and little to no ptosis, the subpectoral technique, in our opinion, produces optimum results. The pectoralis major drapes the superomedial aspect of the prosthesis, softening the transition, and thus creating a more anatomically shaped breast mound (Fig. 53.2). This method also achieves a natural feel, which is especially desirable when using saline implants. The submuscular plane additionally tends to be less vascular, and is associated with fewer sensory alterations of the nipple areolar complex. Also, rates of fibrous capsular contracture are demonstrably lowered with submuscular placement versus subglandular. In addition to improved aesthetic outcomes, there are moreover prospective functional advantages in regard to breast-feeding as well as cancer screening.

Fig. 53.2 Submuscular placement. The author prefers partial submuscular implant placement of implants for improved aesthetic shape, camouflaging of the implant shell, reduced rates of capsular contracture, and improved visualization of mammography. The artist depicts placement through a periareolar incision.

Surgical approach

Although numerous methods have been described in the literature, there are three preferred approaches for breast augmentation: inframammary, periareolar and transaxillary (Fig. 53.3). Dissections may be performed in either plane, with or without the aid of an endoscope.

Fig. 53.3 Incision sites: Examples of periareolar, inframammary crease, and transaxillary incision sites are shown. Note how all heal well with proper placement and patient selection given individual breast anatomy. (This figure incorporates images from Figs 53.5, 53.7 and 53.10.)

The inframammary fold incision (Fig. 53.4) provides excellent results in terms of inconspicuous scars, accessibility for both implant types, and fold modifications (Fig. 53.5). This incision allows for optimal view of the pectoral muscle and breast parenchyma, which permits the surgeon to perform an accurate dissection in either, the submuscular or subglandular plane. The downsides of this approach are the potential increased risk of iatrogenic rupture during wound reapproximation, and implant exposure during the postoperative period given the weight of the implant on the healing incision. Additionally, the access incision must be carefully designed to avoid scar migration to the chest wall or inferior pole of the breast.

Fig. 53.4 Inframammary approach.

Figs 53.5 Inframammary incision.