Patient communication

Previously, decision-making has been relatively arbitrary and based mainly on the surgeon’s experience without detailed measurements and analysis. In the last decade this has changed dramatically. Today, breast augmentation is no longer a ‘volumetric’ procedure, but a dimensional planning process. With the introduction of form-stable, high-cohesive silicone gel implants, dimensional planning has become crucial (Fig.16.1B). A low cohesive or liquid implant filler (Fig. 16.1A) can be deformed and made to fit in a poorly planned implant pocket, but with form-stable devices this is no longer the case.

Fig. 16.1 A, A responsive, smooth silicone gel implant. The so-called ‘tilt-test’, moving the implant in vertical position shows the instability of the upper pole of the implant. This results in deformation and irregularities of the implant. It is likely that this results in increased envelop wear and possible supture long-term. B, A high cohesive, form-stable implant will retain the shape of the upper pole during a tilt-test.

The first step in implant selection is the understanding of the patients’ expectations and desires. They must be told what the tissue limitations are and the drawbacks in selecting large implants should be clearly explained. During patient consultation, a full size mirror is useful to show the patient present and expected breast dimensions. Displacing the breast medial and lateral can easily demonstrate width limitations and the projection can be demonstrated with a calliper and by cupping the hand at the expected projection of the new breast. To use sizers in a tight-fitting sports bra may give the patient a certain feeling for the expected volume, but unless the patient is completely flat, this is of limited use in describing dimensions. The patient must understand that a condition for achieving the demonstrated breast dimensions is that no capsular contraction occurs in the postoperative phase (Fig. 16.2A-D). A severe capsular contraction could alter dimensions considerably, especially if low cohesive fillers are used (Fig. 16.3A-C & Fig. 16.4A & B).

Fig. 16.2 Patient with a right sided capsular fibrosis and soft left breast. Note that the circumferential shrinking of the capsule shifts the implant in a cranial direction. A, B and C, 1 year after the augmentation. D, 6 months after the augmentation. Compare figure D to figure C and note how the implant has shifted in a cranial direction due to the capsular fibrosis.

Fig. 16.3 A, After subglandular implantation in thin patients breasts have an unnatural appearance compared to sub-muscular implantation. B, Illustrates the implant with capsule on the left side and without on the right side. Only limited degree of capsular activity is noted in spite of the unnatural appearance in Figure 16.3A. C, After exchanging to implants in a new submuscular pocket.

Fig. 16.4 A, an anatomical high cohesive form-stable implant should have a snug implant pocket (illustrated on the left breast of A). B, shows the larger size of the implant pocket to allow free movement of the implant. When these breasts develop capsular contraction the implant pocket shrinks circumferentially, which means more cranial movement of the implant. Low cohesive fillers will also deform more to a round spherical shape, reducing the width of the breast, but increasing the projection (illustrated on the left side of B).

Selection of implant filler, shape and surface

Only silicone gel and saline have been used long term and can be regarded as safe and proven. All implants consist of a solid silicone envelope. The surface may be textured or smooth. In the sub-glandular position, textured implants are favoured, whereas with sub-muscular placement, implants can be either smooth or textured (Fig. 16.1A & B). The benefit of silicone as a filling material is its softer, more ‘natural’ consistency and form (Fig. 16.5A-D). Saline implants have a higher rupture-risk, especially if these are not overfilled. However, the latter increases breast firmness. Silicone gel is available in a form-stable version; the round implant will retain its shape in standing position, as opposed to saline or standard responsive silicone gel implants, which become more position dependent. An anatomical high cohesive form-stable silicone implant will also maintain its anatomical shape in all positions. Form-stable silicone implants have a very low incidence of rupture.⁵

Fig. 16.5 A and B, Preoperatively, before secondary breast augmentation; note unnatural appearance with round saline implants. Inappropriate implant dimensions to chest width selected; implant base is too narrow with too large intramammary distance. C and D, After exchanging to form-stable anatomical implants of adequate base dimension.

Preoperative history and psychological considerations

Patients who are unsuitable for surgery must be identified preoperatively. Andersson has proposed a number of questions that, if answered positively, should result in a further appointment before surgery as outlined in Table 16.1.⁶ During the evaluation, it must be stressed that breast augmentation complexity varies greatly. Tuberous breasts, severe ptosis, secondary augmentation cases and pronounced asymmetries are more difficult to correct.

Table 16.1 List of questions that, if answered affirmatively, warrants additional patient assessment

Relevant surgical anatomy

The appearance of the female breast is greatly affected by various factors, particularly heredity. Glandular tissue is covered with a fat layer above the Scarp’s fascia and the amount of fat interspersed in the glandular tissue varies greatly. This part of the breast is relatively unimportant from an anatomical standpoint when it comes to performing breast augmentation surgery, as implants are always placed under the glandular tissue. The most important structure germane to breast augmentation is the pectoralis major muscle. This is a strong, predominant fleshy muscle, tendinous only at its insertion into the crista tubercule of the humerus. The pectoralis major has a fairly thin fascia, stronger and more distinct in the upper pole of the muscle. This is relevant to a sub-fascial breast augmentation. The pectoralis major muscle origins in three distinct parts, first along the sternal half of the clavicle, second on the ventral surface of the sternum and costal cartilage numbers II-VI, and thirdly with a slip on the aponeurosis of the external oblique abdominal muscles. It is of importance to note that the width and length of the muscle has a great interindividual variation. The innervations come from the brachial plexus in the axilla. The muscle is a powerful adductor, which flexes, adducts and rotates the arm medially. The pectoralis minor muscle originates from ribs II-V, near the cartilage-bone junction, so the muscle is more lateral in its origin than the pectoralis major. This is important when performing a sub-muscular breast augmentation where the dissection plane should be between the pectoralis major and minor, making it easiest to dissect from medial to lateral between them. The innervations to the breast come from thoracic segments III-VI. Sensory reduction in the breast after augmentation is a common initial complaint. Most patients do not suffer from this after the initial 6 months of healing, but they should be informed of the possibility of chronic sensory reduction, most commonly related to the lateral intercostal branches coming from the upper lateral quadrant. To minimize risk, large implants should not be selected and the sharp dissection in the direction of the axilla should be minimized. This is the only part of the dissection that should be blunt.

Preoperative markings

Accurate and detailed preoperative marking is essential. Two important questions should be addressed. The first is the vertical location of the implant on the chest wall. If implants are too high the nipple areola complex will point downwards and the upper pole will be too full. If implants are placed too low the breast will be too full in the lower pole. Ideal nipple projection is centrally on the implant, thus the base dimension of the implant is important. Usually, half should be located above the nipple areola complex in the augmented breast and half below it. The ideal postoperative position of the nipple areola complex can be simulated with the arms elevated 45 ° above the horizontal plane; in this position, a line from the nipple to the sternum can be drawn (NS-line) (Figs 16.8A-E & 16.9). As the tissues in the midlines are relatively fixed, measurements of ideal implant height are better done along the sternum. With arms lowered, half of the implant height, or for round implants half the diameter of the implant, is measured distally, and at the distal point a horizontal line is drawn laterally, representing the implants’ lower pole (ILP-line; Fig. 16.10). In patients with asymmetric nipple heights, this will result in different heights of the ILP-line, but the implant will be adequately positioned in relation to the nipple areola complex.

Fig. 16.9 A correctly performed breast augmentation creates an elevation of the nipple areola complex.

Fig. 16.10 To plan the vertical location of the implant on the chest wall should be calculated based on the dimensions of the implant. The way to do this is to elevate the arms 45 ° above the horizontal plane and draw a line between the nipple and the sternum (NS). This arm elevation simulates the nipple position after the augmentation. By lowering the arms and measuring distally along the sternum (where the tissues are fixed) half the height of the implant or the radius for round implants defines the vertical position of the lower pole of the implant. From this distal marking in the midline a horizontal line is marked to illustrate the lower pole of the implant (ILP line).

Secondly, the ideal amount of skin in the lower pole of the augmented breast should be calculated; how long should the nipple-infra mammary fold distance be and, if a sub-mammary fold incision should be utilized, where should this incision be placed? Unfortunately, it is seldom recognized that the amount of skin in the lower pole of the breast is greatly affected by the three factors: the width and projection of the implant; the amount of glandular tissue and the characteristics of the envelope. Higher projecting implants with larger base circumference necessitate longer nipple inframammary fold distance. The ideal nipple to inframammary fold distance in the augmented breast is equal to the distance between the ideal nipple projection point on the ventral surface of the implant measured down to the implant’s lower pole (LVC), plus the added distance for the amount of glandular tissue that the patient has preoperatively (Fig. 16.11A & B). The ideal amount of skin between the nipple and the new inframammary fold is calculated by adding the implant’s lower ventral curvature (LVC) and the distance between the nipple and the ILP-line with arms elevated 45 ° above the horizontal plane. Subtracted from this addition is half the implant height. The implant’s lower ventral curvature is today only available from some manufacturers, but can also easily be calculated with a tape ruler measuring the curvature between a vertical (implants projection) and horizontal axis (implants half baseplate of height for anatomical ones) marked on a piece of paper. Added to this the second number is obtained by elevating the arms 45 °, measuring between the nipple and the previously marked ILP-line, and simultaneously compressing the glandular tissue to simulate the effect of the implant on the glandular tissue. Adding this N-ILP-measurement with the LVC (lower ventral curvature) of the implant, and subtracting half implant height provides the ideal distance between the nipple and the inframammary fold. When marking this distance on the breast tissues should be stretched maximally, simulating a tissue stretch and considering envelope characteristics. The final step is to mark the location of the upper pole of the implant and measure tissue covered here. A pinch-test is done and if the pinch is below 2-3 cm (equal to a tissue cover of 1-1.5 cm) muscle cover in the upper pole of the implant is recommended (Fig. 16.8A-E). These markings and measurements⁷ (the Akademikliniken or AK method) by the author is a more detailed preoperative planning than traditionally used in breast augmentations. This has been developed for form stable anatomical implants but the basic principles of this method is equally applicable for smooth, non form stable and round implants.

Fig. 16.11 The ideal distance (= amount of skin) between the nipple and the new inframammary fold should be calculated based on the lower ventral curvature (LVC) of the implant, measured from ideal nipple projection point on the ventral surface of the implant to its lower pole, plus the difference between the posterior surface of the breast (X) (this is equal to half the height of the implants) and the convex surface on the breast (Y) measured between the nipple and the implant’s lower pole (previously marked ILP line) with the arms elevated 45 ° above the horizontal plane.

Sub-muscular versus sub-glandular implant placement

Indications for both sub-muscular and sub-glandular implant positions exist and the decision should mainly be based on the tissue cover. With the preoperative marking described above, it is easy to measure where the upper implant pole will be located. A pinch and measurement of the tissue with a calliper provides information for implant positioning. If the pinch is below 2-3 cm, this is equal to a tissue cover of 1-1.5 cm and a sub-muscular placement is recommended. With a pinch thickness of more than 4 cm, sub-glandular placement may produce favourable results as such breasts usually are large and a sub-glandular position of the implant may provide more natural aging with gradual ptotis of the breast. Benefits of sub-muscular implant position are that the implant edges are better covered, resulting in less implant edge visibility. It is also less likely that the tissues will become atrophied due to the pressure of the implant. It appears that sub-muscular placement has better long-term aging compared to sub-glandular implants, especially in smaller breasts. Advantages of sub-glandular placements are that the breasts will have no movement during pectoralis muscle activity and a more natural appearance is produced in the ptotic breast. In the tuberous, contracted breast the risk for double bubble deformity in the lower pole is minimized. Sub-glandular implantation is less painful during the initial hours after surgery. The drawbacks of sub-glandular implant positioning can be minimized if the thin pectoralis major fascia is included in the elevated gland. Subfacial implantation is commonly favoured above sub-glandular.⁸

With the modifications of sub-muscular implant techniques, this implant position is more common than sub-glandular/sub-facial. By placing the implant in dual plane position (Fig. 16.12A-D), where only the upper pole of the implant is covered with the muscle, the drawbacks of sub-glandular implantation, such as animation during pectoralis muscle activity, can be minimized.^9,10

Fig. 16.12 Sub-muscular dual plane implant positioning. In dual plane I dissection, the origin of the pectoralis muscle is elevated together with the breast without sub-glandular dissection proximal to the muscle division. This does not permit lateral retraction of the muscle and produce less favourable animation during pectoralis activity. In dual plane II dissection a subglandular pocket is created in the lower pole of the breast up to the level of the nipple areola complex. The origin of the pectoralis muscle is detached distal to this area creating a weaker flap of the pectoralis muscle in its inferior pole. In dual plane III dissection the subglandular plane goes above the nipple areola complex and the muscle is divided as in dual plane II. This procedure is favored in slightly ptotic breasts. In dual plane IV dissection the subglandular dissection is somewhat more extensive than in dual plane III, and the muscle division is higher and more parallel to the fibres of the pectoralis major muscle. Note that the medial part of the muscle dissection still should stay well below the nipple plane. The solid red line indicates the muscle division, the dotted red line extent of sub-glandular dissection and the black dotted line the nipple sternum line with arms elevated 45 ° above horizontal plane (NS).

Incisional approach

The length of the incision depends on the type and size of implant used. Saline filled ones can be inserted through a 3-4 cm incision, whereas form-stable silicone implants necessitate a 4.5-6 cm incision. Four different approaches have been described. Sub-mammary fold incision was first used in the 1970s, this was followed by a periareolar and transareolar incision.¹¹ In the 1970s transaxillary implantation was also popularized.¹² This was followed by the description of transumbilical approach for implant insertion.¹³ Saline implants must be used through the transumbilical route and smooth implants are easier to implant through the axilla. According to the preoperative markings described above, the sub-mammary fold incision has been modified and this ‘new’ sub-mammary fold incision has several advantages.

The new sub-mammary fold incision

By the exact calculation of the ideal distance between the nipple and the new inframammary fold, the ideal position of the sub-mammary fold incision can be calculated (see markings above). A major reason for the previously bad reputation of the sub-mammary fold incision was that resulting scars were not exactly calculated and not placed in the new position of the sub-mammary fold. Arbitrary location of the incision results in worse sub-mammary scarring. The sub-mammary fold incision offers several advantages: less risk for sensory disturbances that may be pronounced in the periareolar and the axillary approach; less contamination of the implant through the sub-mammary fold incisions; and easy inspection and palpation of the implant pocket. The latter is very important if form-stable devices are used, where it is crucial to position the implant correctly and to avoid buckling and irregularities of the implant edges. It is easy to control the exact position of the implant through the sub-mammary fold. Dual plane dissection and the division of the pectoralis origin of the pectoralis muscle is also easier to divide than through the axillary and the periareolar incision (Fig. 16.13A & B), giving superior control of the sub-mammary fold, especially if the scarpas fascia is fixed to the thoracic wall when creating the new fold (Fig. 16.14A-C).

Fig. 16.13 A, Oblique view after submuscular implantation via axillary incision. B, During pectoralis muscle contraction irregularity in the lower pole is seen due to inadequate muscle release, which is much more common via the axillary approach than via the submammary fold, where more control of the muscle division is possible. All the different muscle divisions described in Figure 16.13 are not possible to perform via the axilla.

Fig. 16.14 A, B and C, A patient with a well healed axillary scar and also submammary scar after a secondary breast augmentation. Note that the submammary scar is relatively fixed to the inframammary fold even during arm elevation (C).

The incision is made with a scalpel and dissection is carried on with cutting cautery (Colorado® Tungsten tip and the Valley lab Force FX® cautery in spray and blend mode facilitates a bloodless dissection). The dissection is vertical, exposing the thoracic fascia. Dissection proximal along this fascia creates a lower sub-glandular pocket. In sub-muscular positioning the pectoralis major muscle’s lower origin is exposed and in dual plane I technique the muscle is elevated together with the gland. More commonly used is the dual plane II, where the sub-glandular pocket is created up to the areola plane. The muscle is then divided distally from its lateral border, cutting it horizontally towards the sternum. The muscle is elevated with a cutting cautery. The muscle is divided obliquely, parallel to the chest wall, to minimize the risk of entering between the ribs and intercostal muscles. When entering the sub-muscular plane, the loose connecting tissue on top of the ribs is exposed and this tissue should be left intact on the ribs, minimizing seroma formation and pain, and facilitating postoperative mobilization. The whole dissection is carried out with a cutting cautery. Blunt dissection should be avoided as this increases trauma, pain and seroma. The dissection is first done in the proximal and medial part of the pocket, and from this medial dissection the lateral extent of the pocket is made, minimizing the risk of entering under-neath the pectoralis minor muscle. The only part of the implant pocket that could be blunt is in the direction of the axilla, minimizing trauma to the sensory innervations of the nipple areola complex. The size of the pocket depends on implant type; form-stable textured implants should have an implant pocket that fits snugly, approximately 0.5 cm wider on each side than the implant base width and 1-2 cm in the proximal direction. Smooth implants move more freely in the implant pocket and the implant pocket can be bigger. The medial inferior origin of the pectoralis muscle is released, curved in a proximal direction to the level of the nipple areola complex.

In dual plane III dissection, the sub-glandular pocket is more extensive, passing the level of the nipple areola complex followed by similar muscle dissection as described for dual plane II dissection, above. In dual plane IV dissection,⁷ the extent of the sub-glandular part of the pocket is similar to the dissection in dual plane III, but the muscle is divided from the lateral border at the level of the nipple areola complex, more parallel to the fibres (Fig. 16.12A-D). It is important not to divide the medial origin of the pectoralis muscle higher than the NS-line. Muscle division, inferior-medially, should stay 1-2 cm below the NS-line (see markings above). In sub-glandular dissection, elevation of the pectoralis major fascia, together with the elevated breast, minimizes implant edge palpability and visibility in the upper pole.

Transareolar/periareolar approach

This incision has been widely used. It creates a well-hidden scar and gives better access to the sub-glandular and sub-muscular plane. The origin of the pectoralis muscle can be visualized and divided. Disadvantages include more contamination and sensory nerve affection than the sub-mammary fold incision and it is harder to inspect the whole implant pocket. The size of the areola also has to be at least 3 cm in diameter to insert a medium-sized implant. Many patients and surgeons feel that the periareolar scar is more obvious than a well-hidden scar in the sub-mammary fold.

Incision is made with the scalpel and then continued with a cutting cautery and a Colorado tip, either in the Scarpas fascia plane passing around the gland and retracting in a proximal fashion or straight through the gland.

Implant insertion

After careful control of the haemostasis, the implant can be inserted. Prior to this, drains can be placed; usually through the axilla. However, with the dissection technique described above for the new submammary fold incision, bleeding is usually minimal and no discharge is seen in the drains. The author has, therefore, abandoned the usage of drains in almost all primary augmentation cases. A ‘no touch technique’ is recommended, where the surgeon changes the gloves and is the only one to touch the implant during insertion. The assistant retracts the gland with a long retractor during insertion. When using textured implants lubrication may be recommended. In most cases soaking the implant in saline solution is sufficient. An anatomical form-stable device is easier to insert at 90 °, where the tip is rotated in and then right and left sides are wriggled into the pocket. When the implant has been placed into the pocket the edges should be palpated and controlled so there are no bucklings and irregularities. This is especially important if form-stable devices are used. An anatomical device should also be controlled regarding position. Marking dots indicating the vertical axis of the implants are present in most anatomical devices.

Incision closure

The pectoralis fascia is usually closed with an absorbable suture in the axillary approach, followed by sub-cuticular stitching. In the periareolar approach the dissected gland is usually left open, but can be closed with an absorbable stitch. The new sub-mammary fold incision can be utilized to mark the new sub-mammary fold, resulting in a less conspicuous scar and a better shaped lower pole (Figs 16.14B & C & 16.15). A good grip in the thoracic fascia is taken along the ILP line with an absorbable suture (Monocryl or Monocyn 3/0), passed through the tissues on top of the Scarpas fascia below and above the incision. Usually, three stitches are inserted, one in the midline left untied, while the two lateral ones are tightened. This is followed by a deep dermal ridge suturing with good strong bites of the dermis far away from the wound edge and deeper at the immediate wound edge. This creates a ridging effect and a more relaxed incision line, creating more inconspicuous scars. A sub-cuticular suture is then inserted. Absorbable monofilament sutures are favoured in all layers.

Fig. 16.15 Right breast closed with suture between Scarpas fascia and thoracic wall to fix the incision to the new inframammary fold. Compare to the left side where only Scarpas fascia has been closed, this side moves much more when the breasts are pulled in a cranial direction.

Early and late postoperative complications

Seroma

Blunt dissection adds to the risk of seroma formation. With sharp dissection and by leaving the loose connective tissue on the ribs this problem can generally be avoided.¹⁴ Seromas may also occur late and be related to a sub-clinical infection (Fig. 16.16B). These should be drained and cultures taken before antibiotics are administered.

Fig. 16.16 A, In-growth of fibrous capsule into the surface of textured implant with pore size larger than 300 μm. Note the Velcro-like adhesion between the capsule and implant. B, Non-adhesion of an implant capsule to a textured implant surface. A mucus-like film is present on the implant surface and this is a prerequisite for rotation of the implant.

Asymmetries and implant malposition

Meticulous planning and surgical technique minimizes risk, but capsular contraction or poor tissue adhesion of anatomical textured implants may result in malposition or rotation. To minimize this risk, the pore size of the textured surface should be larger than 300 μm^20,21 (Figs 16.16A & B & 16.17A-D).

Fig. 16.17 A-D, Preoperative planning according to the ‘Akademikliniken-method’ (see description of Figures 16.9, 16.10 & 16.11). Note that arm elevation 45 ° over the head and drawing of a line from the nipple to the sternum simulates nipple position after the augmentation (B). C, 3 months later the implants have settled moderately, but 6 months later due to non-adhesion of the textured implants, too much descent of the implant is noted (D). Compare to opposite reaction due to capsular contraction in Figure 16.2. E, After implant exchange and insertion into new sub-muscular implant pocket, drainage and long-term fixation, a good long-term stable result has been achieved 1 year after the secondary correction.

Deformations during pectoralis muscle contraction

For a natural-looking lower pole of the breast it is important to divide the origin of the pectoralis muscle, as above (Fig. 16.18A-E). By dual plane dissection II-IV, deformations of the breast during muscle contractions are minimized. It is important not to divide the pectoralis muscle too high along the sternum. The medial division should always end well below the height of the nipple areola complex. Especially in ptotic breasts, it is easy to over-dissect the inferior medial origin of the muscle. The preoperative markings of the nipple sternum lines (NS) are a valuable guideline.

Fig. 16.18 A, Patient seeking for secondary breast augmentation where surgeon neglected to address the ptosis of the breast. The deformation is more noticeable during pectoralis muscle activity (B). Preoperative planning for implant exchange and simultaneous mastopexy (C). After secondary procedure in relaxed (D) and tightened pectoralis muscle situation (E).

Implant rupture

All implants may rupture, but the risk for this is greatly related to the generation of implant used and the duration of implantation. Generation two implants, mainly used in the 1970s, have a relatively high risk for rupture after more than 10 years.^25,26 Third generation implants with a mean age of 11 years have been found to have a worst-case rupture prevalence of 8%²⁷ (Fig. 16.19A). It appears that form-stable implants with high cohesive silicone gel have a very low rupture frequency, but these have only been used since 1994 and long-term risks are not finally proven. Implantation times between 5 and 9 years show risks of approximately 1%⁵ (Fig. 16.19B). Extravasation of silicone gel is uncommon and highly related to closed capsulotomy.^23,24 This manoeuvre should be avoided.

Fig. 16.19 A, Explantation of low-cohesive ruptured silicone gel is more difficult than explantation of a ruptured form-stable silicone implant (B).

Antibiotics

These are not needed postoperatively if signs of infections are not present.

Drains

With meticulous technique and sharp dissection with a cutting cautery drains can be avoided without negative effects in most cases. If drains are inserted they are taken out through the axilla and vacuum is applied. Most patients do not need drains after 24 hours, as drainage is normally less than 50 ml per 24 hours.

Dressings

Surgical tape, Micropore® or Steristrip®, is placed directly on the wound and no other dressing is usually needed. A sport bra may be useful to minimize implant movement, especially if form-stable implants are used. Smooth-walled saline implants should be moved around with massage. For patients with large natural breasts, a bra should be used after the initial 3 weeks of healing, whereas patients with small natural breasts do not need a supportive bra after 3 weeks.

Physical activity and exercise

Arm elevation is recommended directly after the procedure. Stretching the pectoralis muscle once every hour during the first 24 hours after the procedure minimizes postoperative pain in sub-muscular implantation. With proper surgical technique and infiltration of local anaesthesia around the breast, postoperative pain is normally minimal. With mild analgesic medication patients should be able to go home within 4-6 hours. Sports and vigorous physical activity should be avoided for approximately 3 weeks. Following this initial healing phase the patient can resume sports, but all sports that exert tension on the scar, or to much implant movement, such as serving in tennis or trampoline bouncing, should be avoided for 3 months. Vigorous stretching perpendicular to the scar may widen it during this period. To improve the final scar appearance, scars should be taped with paper tape (Micropore®) for up to 6 months. This helps the scar to mature and reminds the patient not to exert excessive tension.

Shower and bath

With surgical tape on the wound patients are allowed to shower the first postoperative day, but baths should be avoided for 1 week.

Long-term follow-up

Self-examination on a weekly basis is recommended. This can be done with circular movements of the hand around the breast during showers. If patients experience changes and alterations in the firmness or appearance or notice nodules and irregularities, a follow-up visit is recommended. Otherwise, patients are recommended to call in for a check up 10 years after surgery. MRI investigations of the breasts may be indicated after long-term implantation. No absolute recommendation of when implants should be exchanged can be given, but all patients should be informed that it is likely at some point. Modern implants will probably stay intact for 10 or even 20 or more years.