Breast Augmentation

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Chapter 4 Breast Augmentation

Introduction

In many respects, breast augmentation is the defining procedure for the aesthetic breast surgeon and the ability to obtain outstanding results in a consistent fashion requires sound judgment, technical expertise and fastidious attention to detail. However, with experience comes the realization that developing this skill is harder than it might first appear to be. Perhaps the most significant reason for this relates to the tremendous variability that exists in the preoperative appearance of patients who present for breast augmentation (Figure 4.1) with differences in body habitus, breast size, nipple position and skin elasticity being just a few of the many variables that can significantly influence the final result. Also, there can be significant variability in the goals patients have for their surgical outcome. However, perhaps the most stressful facet of the procedure that must always be respected relates to the fact that these patients will almost uniformly have very high expectations for the quality of their result. Coupling all this with the fact that this high-quality result must be delivered in one operation with the barest minimum of complications highlights the importance that a sound surgical strategy performed with exacting technical expertise will have on achieving a successful outcome.

To this end, over the past decade, many of the finer details of the operation have been re-examined and new techniques described, all in the hope of improving the aesthetic results and minimizing complications. However, despite this in-depth review, for many surgeons the subject of breast augmentation remains as confusing and controversial as ever. This is a direct result of the fact that there are multiple surgical options that can be mixed and matched in numerous ways to create a viable operative strategy (Figure 4.2). For instance, in a given patient one surgeon might choose a smooth round saline implant placed in a partial subpectoral plane through a transaxillary incision, while another might choose a textured round gel implant placed in the subglandular plane through an inframammary fold incision. It is very likely that both approaches would produce equally acceptable aesthetic results that could very well be indistinguishable from each other. Further complicating the matter is the fact that, for nearly every technical decision that is made in planning and executing a breast augmentation, each advantage is directly offset to a greater or lesser degree by a specific compromise or disadvantage. For instance, the subglandular plane can be used to eliminate the potential for postoperative breast animation; however, the risk for a visible implant edge in the upper pole of the breast will be greater. For the novice surgeon, organizing the variables involved in planning a breast augmentation and predicting how the various decisions and approaches will interact with each other can create confusion when attempting to decide the optimal surgical approach for a given patient. It is helpful to step back from this confusing and, at times, contradictory exercise and realize that the basic procedure of breast augmentation simply involves making a pocket and inserting a spacer (implant) that, together with the existing soft tissue, will create the final breast form. When the existing soft tissue layer is thin, the implant and pocket location will to a greater degree determine the eventual shape of the breast and greater care will be required in choosing the best implant and pocket plane to provide an optimal result. When the soft tissue layer is thicker, these variables will have a comparatively less significant impact on the shape of the breast, and specific implant and pocket plane selection becomes less important. The goals of this chapter will be to describe the variables that need to be addressed when evaluating an individual patient for breast augmentation, provide a system for implant selection that can help guide the surgeon to select the optimal implant for a specific patient and to describe the technical details of the various surgical approaches that must be mastered successfully to perform the procedure.

Preoperative Planning

When planning a breast augmentation, it is helpful to realize that there are three basic decisions that must be made when designing a surgical strategy to augment the breast. These decisions involve choosing the location of the access incision, choosing the desired pocket plane and selecting an appropriate implant that will create the desired result. Choosing from the available options for each decision in such a way that each choice complements the other in the best way possible is the basic goal of preoperative planning.

Incision

When planning an incision for breast augmentation, the need for locating the incision in a position that allows for easy pocket dissection and implant insertion must be balanced with the desire to ‘hide’ the incision in an inconspicuous area. With this in mind, there are four potential incision locations for breast augmentation (Figure 4.3).

Periareolar

Although in terms of popularity, the periareolar incision is second to the inframammary fold incision, it remains as an attractive option for many plastic surgeons for two reasons. First, the resulting scar generally heals in a fine line fashion and is essentially imperceptible in many patients (Figure 4.5). The fact that the scar is situated at the junction of the pigmented areolar skin with the lighter lower pole breast skin assists greatly in visually masking the scar. Second, the only time the scar is potentially visible is when the breast is bare which, for many women, occurs only in controlled private settings. One unique situation where the periareolar incision has particular advantage is in the patient who presents with very small breasts with little to no inframammary fold. Here, the breast often cannot be augmented enough to cause the breast to fold over an inframammary fold incision with the result being an immediately obvious and visible inframammary fold scar. In these cases, rather than risk scar visibility, a better option is the periareolar incision location, where the scar is better camouflaged. Other advantages of the periareolar incision location include the fact that, as with the IMF incision, direct access is afforded to the breast, which allows accurate pocket dissection and direct hemostasis. The incision is generally made along the inferior hemisphere of the areola, at the junction with the lighter lower pole breast skin. From here, two approaches can be used to access the underside of the breast and create the pocket:

The most direct approach involves dissecting straight down through the breast to the subglandular space (Figure 4.6). With this approach, any pocket can be created, as in the IMF incision. Along with excellent access to the breast that is provided by this incision location, there are several other important advantages afforded by this approach. By dividing the breast parenchyma essentially in half, tethering contractures that can result from a tight parenchymal envelope can be partially released, allowing the placement of an appropriately sized implant of sufficient size to augment the breast adequately. Also, it is easier to dissect accurately and position the inframammary fold by approaching it from above through a periareolar incision rather than through an incision made directly in the fold itself. By approaching the fold from above, the entire sweep of the fold can be assessed as it is dissected free without the potentially distorting influence of an incision made directly in the fold. Therefore, accurately maintaining or, more importantly, lowering the fold can be performed with greater precision. As with the IMF incision, placement and orientation of virtually any device is easily performed through this approach. It must be emphasized, however, that all of these manipulations will be hindered by an incision length that is too short. Remembering that the circumference of a circle can be calculated using the formula π×D, where π is roughly 3.14, a 4 cm areola will provide a static inferior hemiareolar incision length of 6.3 cm (Table 4.1). The elasticity of the skin and surrounding soft tissue will also influence the ease with which an implant is inserted. Generally speaking, however, any attempt to use the periareolar approach with pre-existing areolar diameters of less than about 4 cm can become problematic when attempting to place larger round silicone gel implants, implants that are textured or any of the various ‘cohesive’ or stiffer anatomical gel implants that are also textured. The potential to damage the implant during the process of insertion becomes greater when attempting to ‘stuff’ or force an implant through a restricted opening. Shorter incisions can be used with saline implants of virtually any size without difficulty as these implants’ shells can be inserted unfilled and then brought to volume once the shell is positioned in the pocket. The major disadvantage of the direct transparenchymal approach relates to the potential release of bacteria from the breast ducts that are divided during the dissection. Should these bacteria successfully seed the pocket around the implant, the potential for postoperative infection with loss of the implant would likely increase. Also, should the bacteria simply colonize the pocket, biofilm formation could develop, resulting in varying degrees of capsular contracture.
The second approach to pocket development through a periareolar incision involves leaving the breast mound undisturbed and instead angling inferiorly and elevating a lower breast flap at the level of the superficial fascia down to the inframammary fold (Figure 4.7). At the fold, dissection then turns superiorly deep to the breast to create the desired pocket. This approach, as with direct division of the gland, provides for accurate identification of the level of the inframammary fold as it is approached from above. Also, the volume of the pocket can be increased by allowing the lower pole of the gland to ride up away from the fold during closure after the implant has been placed. If the skin envelope is sufficiently elastic, this maneuver can expand the pocket space and thus allow the placement of a larger device when indicated without creating undue tension due to pocket restriction. If the breast is allowed to slide up away from the fold to allow a larger implant to be placed, a smooth interface between the lower breast flap, the implant and the remaining breast parenchyma must be present to prevent a lower pole contour deformity (Figure 4.8). The disadvantage of this approach is that the dissection is more complicated and accurate identification of the breast fascia and creating what amounts to a lower mastectomy flap evenly can be a technical challenge, particularly when the periareolar incision length is short. Also, the exposure is more limited than with other approaches and implant insertion can be more difficult. There is also theoretical concern about affecting sensibility of the nipple–areola complex (NAC). Although there is literature support which documents that the periareolar incision is no more prone to altering the sensation of the NAC than the inframammary fold incision, if retaining sensation is of vital concern to the patient, it might be more prudent to use an incision remote to the NAC to avoid any further possibility that nerves could be inadvertently sectioned or stretched during flap dissection and pocket development.

Table 4.1 The circumference of a circle can be calculated using the formula π× diameter. By using this formula and dividing the circumference by two, the static length of a periareolar incision can be calculated for areolas of several different commonly encountered dimensions

Areolar diameter (cm) Incision length (cm)
3.0 4.7
3.5 5.5
4.0 6.3
4.5 7.1
5.0 7.9

Transaxillary

The transaxillary incision provides an access site to the breast which heals with a well-hidden and, in most instances, imperceptible scar that is not located on or near the breast (Figure 4.9). As such, it is not generally recognized as a telltale sign of previous breast surgery. This significant advantage must be weighed against the potential for compromised accuracy in pocket dissection due to the remote location of the incision as well as the occasional patient who forms a bad scar in this otherwise visible location. There are two techniques to utilize this incision as it relates to pocket development. In both methods, the incision is located high in the axilla and is oriented horizontally at a point just lateral to the lateral margin of the pectoralis major muscle. The skin is incised and spreading dissection is used to identify the lateral border of the pectoralis major. At this point the underside of the pectoralis can be separated bluntly using a sound-type elevator to develop this plane, which opens up very easily. Crossing vessels from the chest wall to the muscle are simply avulsed and go into spasm, which usually checks the bleeding. Any tethering of the fibers of origin of the pectoralis major that adversely affect the shape of the breast are released by likewise avulsing these fibers loose until the pocket of the desired shape and dimension is developed. The implant is inserted and the incision closed. Clearly, the major difficulties associated with this approach involve the blunt and relatively blind nature of pocket development and the potential for uncontrolled bleeding due to the lack of direct control of bleeding points. Even with these potential difficulties, it must be pointed out that many surgeons can and do use this approach with success. However, in an attempt to increase the control afforded by this approach, some surgeons have incorporated endoscopic technique into the procedure. Once the plane on the underside of the pectoralis major is developed, an endoscope is inserted and, with the aid of standard endoscopic instruments, bleeding points are controlled and the fibers of origin of the pectoralis major muscle are released as needed under direct endoscopic vision to accurately create the desired pocket and position the inframammary fold with precision. Combining the use of the endoscope with the well-concealed transaxillary incision is an excellent way to combine the advantages of direct pocket development with a remote and imperceptible scar. The disadvantages are related to the requirement for extra instrumentation, the additional technical expertise required to utilize the endoscope and the potential for bleeding that may be difficult to control even with the aid of the endoscope, particularly if the second intercostal perforator in the upper inner portion of the pocket is inadvertently divided. Additionally, plane selection is limited as, although it may be technically feasible to utilize the subglandular plane with this approach, it is difficult and, practically speaking, most surgeons use the subpec­toral plane with this technique. It must also be pointed out to the patient ahead of time that, should future problems develop such as capsular contracture or implant malposition, many patients are going to receive an additional scar on the breast in the course of correcting the problem. Finally, this technique allows saline implants to be placed without difficulty; however, larger gel devices, textured devices and anatomically shaped cohesive gel devices all may prove to be variably difficult to insert without damaging the implant. These potential disadvantages do not diminish the utility of the transaxillary approach and many surgeons do use it successfully. However, all of these factors must be taken into account when contemplating the use of the transaxillary incision location.

Transumbilical

In a further effort to erase any stigmata of a procedure on the breast, the transumbilical breast augmentation (TUBA) procedure has been developed. In this approach, an incision is made in the umbilicus and a hollow trocar is bluntly inserted through the subcutaneous tissue, angling upwards toward each breast. The pocket, either subpectoral or, more recently, subglandular, is bluntly opened enough to allow the passage of an uninflated temporary ‘expander’. This device is attached to a long fill tube which exits through the umbilicus. By over inflating the ‘expander’ with air, the pocket is developed bluntly as the muscle and/or breast is avulsed away from the more rigid chest wall. The more dense attachments of the inframammary fold prevent to some degree inadvertent lowering of the fold, and the pocket opens more or less under the breast. The ‘expander’ is deflated and removed and the final saline implant shell is passed through the trocar uninflated and attached to a second long fill tube. The implant is filled with saline to the desired fill volume and the fill tube and trocar are removed to complete the procedure. TUBA remains a controversial procedure. It must be stated that the scar generally is well hidden and some surgeons are able to obtain consistent aesthetic results using the technique. However, the disadvantages and potential complications are significant and must be taken into serious consideration when contemplating the approach. Due to the limited access tunnel, it is possible to use only saline implants, which limits implant selection. Also, because pocket dissection is performed bluntly from a remote location, control over the size, location and symmetry of the dissection space is compromised compared to the direct control afforded by incisions located closer to the breast. If bleeding occurs, it cannot be stopped other than with direct pressure, which increases the potential risk for hematoma development. One potential comp­lication unique to the TUBA procedure involves the creation of permanent soft tissue distortion with visible grooving in the upper abdomen extending up from the umbilicus to the breast that can develop in trim patients as a result of the trocar passing through the thin subcutaneous layer. Finally, any revisionary procedure that cannot be performed through the periumbilical access site will require an additional separate incision on the breast. For these reasons, TUBA is viewed less than favorably by many surgeons and the lack of direct control of many of the factors involved in offering consistent results in breast augmentation is deemed enough of a disadvantage to make the remote and inconspicuous umbilical scar an unreasonable tradeoff.

Pocket Plane

As with many aspects of breast augmentation, selection of the most appropriate pocket plane for placement of the implant has been an evolving concept as operative technique has matured over the years. As a result, there are four basic options for pocket plane development.

Complete submuscular

Early on in the development of breast augmentation as a viable aesthetic procedure, it made intuitive sense to place the implant directly under the breast on top of the underlying musculature. It soon became clear, however, that, with this technique, capsular contracture was an alarmingly common complication and one possible etiology was thought to be bacterial contamination of the implant space from the ducts in the overlying breast. Therefore, in an attempt to isolate completely the breast implant from the overlying breast parenchyma and thus minimize any bacterial contamination, the submuscular pocket was developed. In this procedure, a pocket is created under the pectoralis major muscle by lifting the lateral margin of the muscle away from the chest wall and undermining the muscle over to the medial fibers of origin just lateral to the sternum. Typically, every attempt is made to keep the fibers of origin along the inframammary fold intact to prevent the implant from slipping out from under the muscle inferiorly thus preserving the completely submuscular location of the pocket. Laterally, the muscle fibers or simply the superficial fascia of the serratus anterior muscle are elevated away from the chest wall and the implant is slipped under this muscle/fascial layer. By approximating the lateral margin of the pectoralis major to the serratus muscle/fascia, the implant is completely isolated from the overlying breast parenchyma (Figure 4.10). Theoretically, providing a barrier to potential bacterial seeding of the implant space from the breast ducts will prevent or at least moderate the subsequent development of capsular contracture. Also, keeping the inferior muscle fiber attachments intact is thought to provide strong support to the inferior pole of the breast, which can prevent postoperative inferior migration or ‘bottoming out’ of the breast implant. Also, by covering the implant with a layer of muscle, the contours of the superior and superomedial borders of the breast along the edge of the implant are softened, creating a more natural breast shape. While these factors may be an advantage, there are significant drawbacks to this technique. Perhaps the greatest problem associated with the use of the completely submuscular pocket is the potential for superior implant malposition. This is because anatomically, in many patients, the position of the inferiormost fibers of origin of the pectoralis major muscle can be located slightly above the location of the attachments of the inframammary fold (Figure 4.11). When this relationship is present, placing an implant in a completely submuscular pocket or, for that matter, even in a subpectoral pocket, without release of the inferior fibers of origin of the pectoralis major muscle will not allow the breast implant to sit low enough and it will be appear to be superiorly malpositioned in relation to the position of the breast mound on the chest wall. The resulting breast contour will then very likely demonstrate a superior pole bulge with the breast appearing to fall away from the inferior pole of the implant. When severe, this appearance has been referred to by some as a ‘snoopy dog’ type deformity (Figure 4.12). The identification of a mismatch in breast position versus implant position can be difficult to appreciate intraoperatively as the implant malposition may not become apparent until the patient is placed upright. Lying supine, the breast mound tends to shift superiorly and an implant in a submuscular pocket may appear to be well matched to the breast positionally. It is only later when the patient is seen upright in the office that the malpositioned breast implant becomes apparent. It is likely that this phenomenon is at least partially responsible for the widely held opinion that submuscular implants tend to ‘ride high’. It may be that the so-called high-riding implant more accurately represents an implant that was unwittingly malpositioned superiorly at the time of surgery. This observation is but one of many that underscores the importance of sitting any breast patient up 80 to 90 degrees during the procedure so these types of relationships can be accurately assessed intraoperatively and appropriate changes made in implant position as needed. Another limitation associated with the use of a submuscular pocket relates to the volume of the space that can be opened up under the muscles. The pectoralis major and serratus anterior muscles are normally closely applied to the chest wall in their resting state and the degree to which they can be elevated away from the chest wall and still keep the peripheral attachments intact is limited. For this reason, larger implants may not comfortably fit within the confines of the dissected pocket. Also, should the pocket be constricted at all, due either to an inelastic muscle cover or to the use of a large volume device, there is a tendency for the implant to become compressed, particularly in the lower pole, resulting in lower pole flattening and excess upper pole fullness. It is for these reasons that the total submuscular pocket is used only sparingly in breast augmentation.

Partial subpectoral

In an attempt to address the apparent difficulties associated with the completely submuscular pocket, the partial subpectoral pocket was developed. In this procedure, the pectoralis major is released along the lateral border of the muscle and the subpectoral space is developed as before. Here, however, no portion of the serratus anterior is elevated at all and the inferomedial fibers of attachment of the pectoralis major muscle are released, allowing the muscle to retract up and away from the inframammary fold. The net effect of this release is twofold. First, the tension on the pocket is reduced significantly as a result of releasing the muscle fiber attachments. When the total submuscular pocket is used, the broad, flat pectoralis major can function as a tethering layer, preventing the pocket from expanding fully to accommodate the implant. By releasing the inferior attachments of this tethering layer, the muscle is released and the skin envelope of the lower pole of the breast is recruited to assist in defining the dimensions of the pocket. The result is a bigger pocket with less compressive force on the implant and a more compliant soft tissue/implant interface, allowing the creation of a softer breast. Second, as a result of releasing the muscle along the inframammary fold, the implant can now be positioned low enough to place the inframammary fold in an anatomically correct position. As a result, the upper portion of the implant remains covered by the pectoralis major muscle but the lower portion of the device is in contact with the underside of the breast (Figures 4.13, 4.14). The portion of the implant that is covered by muscle will change from patient to patient as breast position on the chest wall and the exact point of origin of the pectoralis major is subject to anatomic variation. However, the ultimate effect of this pocket plane is to once again soften the upper medial pole of the breast due to the padding created by the muscle and yet allow the breast implant to be positioned low enough on the chest wall to anatomically fill out the breast contour. The pocket is also very easily developed either under direct vision or bluntly through any incision location. The subpectoral pocket is also the preferred pocket location for women undergoing mammographic screening of the breast as the breast implant is relatively easily pushed up and out of the way, a maneuver that affords better breast compression and a more complete mammogram.

While the use of a partial subpectoral pocket successfully addresses several of the problems noted with a total submuscular pocket, there are some disadvantages associated with the technique. Technical skill must be exercised in the undermining and releasing of the muscle to create a breast shape that will be symmetric from side to side. While this may seem to be a straightforward endeavor, it can actually require a fair bit of care to accomplish symmetric release of the muscle inferiorly as factors such as pre-existing asymmetry in the fibers of origin as well as a basic asymmetry in breast size and shape itself can come into play. Failure to release the muscle symmetrically can lead to postoperative implant malposition. Also, due to the fact that the integrity of the total muscle cover is interrupted, a portion of the implant becomes exposed to the overlying breast parenchyma. Theoretically, bacterial seeding of the implant space could occur, possibly leading to capsular contracture. Despite this concern, numerous studies have concluded that the subpectoral plane is associated with a reduced capsular contracture rate as compared to the subglandular plane. This apparent inconsistency between theory and observation underscores the fact that capsular contracture is a multifactorial process that remains incompletely understood even today. Therefore, despite the technical challenges that use of the partial subpectoral pocket presents, the advantages associated with use of this technique are significant and it remains as the standard approach for the vast majority of plastic surgeons who perform breast augmentation.

When either the total submuscular or partial subpectoral pocket plane is used, it must be recognized that the overlying musculature retains its contractile ability. As a result, when a breast implant is placed under the pectoralis major muscle, the implant will be compressed when the muscle contracts. Typically, this movement tends to draw the implant in an up and out direction and this directed compression creates a contour deformity in the breast that can easily be seen when the patient places her hands on the hips and pushes inward. Occasionally, the deformity is so prominent that the distortion in breast shape can be seen through tight-fitting clothes. The magnitude of the deformity caused by this breast animation is highly variable and, fortunately, it is usually only minimal to moderate in severity (Figures 4.15, 4.16). However, at times, the degree of the distortion created by contraction of the pectoralis major muscle can be dramatic (Figure 4.17) and, in revisionary patients, undesired breast animation is often one of many issues that can lead patients to seek re-operation (Figure 4.18). In an attempt to head off any potential postoperative dissatisfaction and ensure a fully informed patient, it is very reasonable to discuss breast animation as a potential complication during the preoperative evaluation and education of the patient. Short video clips (DVD clips 2.01, 2.02, 2.03, 2.04) are very instructive and can ensure that the patient understands completely the rationale for using the partial subpectoral pocket and what effect that decision may well have on her postoperative result.

One of the most common complaints I have noted in patients who present for revision after primary breast augmentation relates to the degree of breast animation that is present as a result of the implant being placed under the pectoralis major muscle. At times, this is the major presenting complaint and, whether true or not, most patients are adamant that they were never counseled that such animation could occur. As a result of this experience, it is now my practice to show every potential breast augmentation patient a short video clip of a mild animation as well as a major animation deformity. This is then contrasted with a video clip of a patient who has undergone a subglandular augmentation with no animation deformity. It has been my observation that most patients are quite put off by the potential for breast animation when they have the opportunity to see an example of it preoperatively and will opt instead for the subglandular plane, if they are otherwise appropriate candidates. If the patient is not a candidate for subglandular placement or capsular contracture is a prominent concern, there is at least an understanding as to what the sequelae may be when the implant is placed under the muscle. Although this discussion represents a small part of the overall process of patient education, the benefits have been significant in that the potential for patient misunderstanding regarding this issue is essentially eliminated. This exercise is an example of an old axiom relating to the art of a successful practice, ‘if you tell a patient about a complication beforehand and it occurs, you are a prophet. If you try to explain away the complication after it occurs, you are covering up.’

Subglandular

The second most commonly utilized pocket for breast implant placement is the subglandular pocket. In this procedure, the subglandular space above the pectoralis major muscle is opened leaving the pectoralis muscle fascia attached to the muscle (Figure 4.19). The space dissects open readily and the limits of pocket development can be precisely controlled, which eases the technical challenge of dissecting pockets of the same dimension and location for each breast. Crossing vessels and nerves can be identified and preserved medially and laterally as desired and the pocket can be easily accessed through either a periareolar or an inframammary fold incision. Any type of implant can be used with a subglandular pocket and shaping maneuvers such as scoring of the underside of the breast to release tethering constrictions are greatly facilitated due to the direct exposure of the gland. As a result of placing the implant above the muscle, postoperative animation of the breast is markedly diminished and, at most, only a slight shape change may occasionally be noted with contraction of the pectoralis major muscle due to tethering of the capsule to the muscle. Typically, the recovery after undergoing a subglandular breast augmentation is more straightforward with many patients reporting a less painful experience overall. Despite these advantages, the subglandular pocket is used with care as the disadvantages can be significant. Perhaps, most importantly, it is generally agreed that the incidence of capsular contracture is greater in subglandular breast augmentation. What remains unknown is what effect that newer breast implant designs will have on this complication. More recent silicone gel breast implants have been designed to have an outer shell that is much more resistant to gel bleed than earlier implants and recent studies have reported rates of capsular contracture that are not much different from those associated with subpectoral placement. Perhaps just as important is the effect of the subglandular pocket on breast shape. Because the upper inner portion of the pocket is not padded by the pectoralis major muscle, implant edge visibility and palpability in this area can become an issue in thinner patients who do not have enough native breast parenchyma to mask the shape of the underlying device. This implant visibility becomes more apparent as the patient flexes the pectoralis major muscles and a sharper medial and superior implant margin can become evident (Figure 4.20). For these reasons, many surgeons limit the use of the subglandular pocket to those patients who have an upper chest soft tissue thickness of 2 cm or more, or in patients who will require soft tissue scoring on the underside of the breast as in patients who present with a tubular breast deformity. Also, in mastopexy patients, the soft tissue lifting effect of placing an implant under the breast is enhanced if the pectoralis major muscle is not positioned as a potentially tethering layer inhibiting implant projection. As a result, many surgeons will choose the subglandular plane for those patients undergoing augmentation mastopexy.

Subfascial

Closely related to the subglandular space is the subfascial pocket. This technique was designed in an attempt to minimize the potential disadvantages traditionally associated with the partial subpectoral pocket related to postoperative breast animation and yet preserve the improved upper and medial pole contour that the partial subpectoral pocket can provide. In this technique, the lower border of the breast is elevated along with the investing fascia of the pectoralis major muscle. Initially, this plane can be somewhat difficult to develop as the attachments of the breast septum must be dissected free as they course transversally across the mid-aspect of the pectoralis major muscle. Associated with this fascial attachment will be several prominent perforators that are easily controlled. Above this point, however, the fascia comes up easily and any small bleeding points that are encountered are easily controlled. Dissection then continues superiorly under the breast until the superior extent of pocket dissection is complete (Figure 4.21). Although quite thin, theoretically this fascia is thought to provide a tethering force around the perimeter of the breast implant that then softens the contours of the peripheral edges of the breast, leading to less implant visibility. It is postulated that this effect is similar to the softening of the superomedial implant edges that occurs with partial subpectoral placement, but without the attendant subpectoral distortion that variably occurs when an implant is placed under the pectoralis major muscle. In practice, this plane is rather easy to develop; however, the fascial layer is quite thin and any resulting improvement in breast shape that occurs is modest at best with other factors including body habitus, implant style and size and implant fill exerting a much more profound impact on breast shape. For this reason, use of the subfascial pocket has yet to attain wide popularity. One unexpected advantage that can seen when using this plane relates to the accuracy of pocket dissection. By elevating the fascia with the breast in the medial portion of the pocket, it is technically easier to identify and preserve the medial internal mammary perforators and avoid inadvertent injury to this vigorous source of blood supply to the breast. Another more theoretical advantage relates to a potential shaping advantage afforded by differentially scoring the fascia in the lower half of the breast. The resulting release of tension in the lower half of the pocket coupled with a mild fascial-induced tethering in the upper half can create differential tension on the pocket that tends to restrict upper pole fullness and maximize lower pole projection. However, whether or not such differential pocket dissection can aid in ‘shaping’ the subsequent breast implant, creating an improved breast shape over the long term, remains to be demonstrated.

Implant Choice

After selecting an incision location and a pocket plane, the last and arguably most important decision to be made involves selecting a breast implant. A properly chosen breast implant that artistically complements the overlying soft tissue framework has a tremendous impact on the quality of the overall result. To this end, there are a host of different devices that have been developed over the years, all designed to improve the aesthetic results of breast augmentation while minimizing the potential complications. Design variables such as round versus anatomically shaped devices, smooth versus textured surfaces, saline versus gel fill, different types of gel fill (i.e. cohesive gel), implants of differing projections and combination gel/saline implants can all mix and match in numerous ways to create hundreds of different devices. In the face of this complexity, choosing the ‘optimal’ implant for a specific patient can be a daunting challenge.

Despite this apparent complexity, the fact remains that there are a wide range of different implants that, for a given patient, would be equally optimal and even more that would be practically acceptable. The ultimate determining factors become the thickness of the overlying soft tissue cover of the breast and the degree of ptosis. Patients with 2 cm or more of fat and breast parenchyma at the peripheral margins of the breast and, in particular, in the superior pole of the breast will do very well with almost any type of implant. In these patients, any asymmetry, wrinkle or mild malposition problem will be masked by the native breast volume. Put another way, when the implant provides roughly 75% or less of the total volume of the breast, less stress is placed on the implant to determine the final shape of the breast. However, as patients become thinner, or as increasing degrees of ptosis become present, specific implant selection begins to play a more important role and must be more carefully individualized for each patient as any imperfection in the implant will tend to be more noticeable and may potentially detract from the quality of the aesthetic result.

Preoperative Evaluation

Prior to performing breast augmentation, a basic breast history is obtained that notes the changes that have taken place in the breast over time and documents the current condition of the breast. Pertinent issues such as the number of pregnancies and deliveries are noted along with information about whether or not breast-feeding was performed and for how long. It is very helpful to inquire of patients how big their breasts became with breast-feeding as this is often the aesthetic goal these women are seeking after breast augmentation. A history of any previous breast biopsy is noted and the location of that biopsy and the associated scar is documented as particularly prominent or long scars could potentially influence access incision choice. The current bra size is noted as is the patient’s height and weight. Any fluctuations in the patient’s weight over the past year should be noted as it is advisable for the patient to present for surgery at a weight that is stable before making decisions about implant size. Lastly, the patient is asked in precise terms, what she would like to accomplish with the procedure. Issues such as volume, shape, ptosis and firmness are common concerns that motivate many women to pursue breast augmentation and what role each of these variables plays in determining the goals of the patient must be documented so that the surgeon has a clear understanding of what the patient’s expectations are for the procedure. Heading off any misunderstandings at this point is very important in preventing patient dissatisfaction postoperatively.

When evaluating a patient for breast augmentation, it is incumbent on the physician to recognize the propensity of the breast to undergo malignant transformation. For this reason, preoperative mammographic screening of the breast is liberally utilized. Certainly, for any patient who has either a personal history of any previous breast pathology or mass, or for any patient with a family history of breast cancer, a preoperative mammogram is highly recommended. If no risk factors are present, a reasonable approach used by many surgeons is to obtain a mammogram for anyone over the age of 25 prior to performing a breast augmentation. Should any type of suspicious or questionable abnormality be noted on the mammogram, breast augmentation is delayed until the abnormal area has been proven to be benign, most preferably via biopsy, although at times further views on mammogram may help confirm the benign nature of a suspicious area.

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