Highly Cohesive Textured Form Stable Gel Implants: Principles and Technique

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CHAPTER 23 Highly Cohesive Textured Form Stable Gel Implants

Principles and Technique

Charles Randquist, Örjan Gribbe

Summary/Key Points

In order for a breast augmentation practice to advance and improve, its surgeon must constantly strive toward fewer complications and reoperations, predictable long-term results and a better experience for the patient. The surgeon must be attentive in the communication with the patient and adhere to certain principles, both during implant selection and surgery. These principles can be summarized by the following ‘five Ps.’

1. Patient selection is most crucial and requires an attentive and thorough surgeon along with well trained staff.
2. Preoperative planning with implant selection and marking is critical in order to gain a predictable result, and should be based on a careful assessment of the patient’s measurements and features. Respecting the patient’s base width provides important guidance when choosing implants. Lowering of the inframammary fold is often a must when positioning the implant.
3. Proportional thinking during implant selection, taking the patient’s height and the characteristics of her hips, waist, chest and shoulders into consideration leads to attractive results.
4. Performance during surgery is pivotal. Bloodless, swift and atraumatic surgery, performed under aseptic conditions, with a precise design of the implant pocket and without using sizers or drains lessens the risk of complications. This also assures a cosmetically controlled long-term result.
5. Postoperative care with early mobilization, having the patients spend one postoperative night at the clinic and with responsible follow-ups by the surgeon adds safety and increases the patient’s confidence and overall satisfaction.

This chapter reflects the experience of the senior author (Randquist) with cohesive and highly cohesive textured silicone implants. Randquist has performed more than 2000 breast augmentations over a 14-year period using these implants.

Indications

The indications for primary breast augmentation that have been adopted by the authors include:

• Breast aplasia, defined as an absence of breasts and inframammary fold.
• Breast hypoplasia, which is primarily according to the patient’s subjective opinion. It is up to the plastic surgeon to accept this definition, thus accepting her for surgery.
• Breast asymmetry, a difference in breast size or chest wall projection that can be corrected by differently shaped or sized implants. At least one of the breasts should be considered aplastic or hypoplastic in these cases.

Patient Selection

The authors and their staff follow several selection criteria when accepting a patient for breast augmentation surgery. The selection process starts when the patient calls to book the consultation. At this point the staff follows certain guidelines. First of all, the booking must be made by the patient herself; it cannot be done by a spouse or relative, for example. Furthermore, under-aged patients (18 years old in Sweden) cannot consult without an accompanying parent.

During the consultation, it is imperative to evaluate several factors related to the patient’s body characteristics and her state of mind. Central to the process of selecting patients for any type of aesthetic surgical procedure is the well-being and safety of the patient. Wrongly scheduling a patient for surgery will be detrimental to the patient, the surgeon and the surgical practice. At times, the ‘best’ surgery is the one never performed.1

If the practice is marketed, the surgeon should be especially cautious, as there exists a possibility that proactive marketing might encourage patients to act on impulse. Such patients are likely to have less knowledge about the procedure compared with patients who come through personal recommendation or thorough research. The surgeon and staff must therefore be extra informative.

Correctly selecting patients is difficult. It requires verbal communication skills, genuine interest in the patient, and the ability to listen. While some of these capabilities can be learned through academic study, a successful patient selection also requires a great deal of experience. For the young plastic surgeon, it is therefore very important to have the proper mentor.

Medical history

In the authors’ practice, the patient’s physical health is carefully evaluated by the surgeon in charge and the anesthesiologists. Surgery can be scheduled if the medical risk of the procedure, including anesthetic, is expected to be negligible. Furthermore, if the patient has an ongoing psychiatric condition she should have documentation from her treating doctor stating that she is suitable for surgery and that the procedure will not worsen her condition.1

Patient motivation

During the consultation, the patient should seem comfortable with her decision and not be hesitant. It is imperative to ascertain that it actually is the firm will of the patient herself to follow through with a breast augmentation. The patient should for some time have thought through the consequences of the procedure and it should not be a spur-of-the-moment decision.

Even though many patients state that they have been considering the procedure for as long as they can remember, the standard questions should always be ‘…and why have you decided on this procedure right now?’. The authors always make sure that the patient is in a stable social situation and that she, for example, has not recently experienced an emotional trauma, such as a divorce.

Patient expectations and requests

It is always the surgeon’s responsibility to inform the patient of the end result, regarding what shape is achievable, given her specific body characteristics. Involving a patient in the implant selection process without risking long-term adverse consequences requires a delicate balance. At times, patients present unrealistic expectations that make them unsuitable for surgery. An example is the very thin patient with ptotic breasts in need of a submuscular breast augmentation, but who refuses a necessary mastopexy. Another example is the patient wanting too large implants that might look disproportionate and, more importantly, exert excessive pressure on the tissue. The surgeon, together with the patient, should choose implants based on the patient’s chest wall and existing breast tissue, using different kinds of shaped implants to create the desired shape of breast. It is therefore necessary to have a thorough, ongoing discussion between surgeon and patient. The patient should be denied surgery if she requests unreasonably large implants compared with what the surgeon believes would be sound in the long term.6,7

Much less frequent is the case with a patient who firmly requests extremely small implants. Implants that are too small, or have the wrong shape, could in the surgeon’s eyes lead to an unsatisfactory aesthetic result.

Body dysmorphic disorder

As when dealing with any cosmetic surgical procedure, it is important to exclude patients suffering from body dysmorphic disorder, as surgery only reinforces the condition. During the consultation, it often becomes evident if a patient is suffering from body dysmorphic disorder, but at times, a few screening questions are required. If the patient has a history of bulimia or anorexia, she should have been declared healthy at least six months prior to the consultation.2,3

Patient information and education

Whether patients request too small or too big implants is, of course, subject to opinion. However, in order for us to strive for maximal satisfaction rates, combined with lower complication and reoperation rates, we need to explain to patients who are sometimes lost in a desire for volume that volume, as such, is less important than how that volume is distributed. The philosophy behind this is the desire to shape rather than just volumize a breast.

Each patient should be made as knowledgeable as possible through extensive preoperative information. The information may, for example, be delivered through an informative web-site, verbally and in written form. If the patient is well informed prior to the consultation, the discussion between the surgeon and the patient becomes more meaningful and the patient can participate fully in the choice of implants. It is imperative that the patient understands that additional surgery might be required at some point in the future. The patient should also be aware of the risk of capsular contracture and its consequences.8

Therefore, a patient who does not show any interest in the learning process is not an optimal patient to operate on.

Body characteristics and implant range

The characteristics of the patient’s chest wall, existing breasts and breast implants collectively determine the end result. Understanding the differences in configuration and choosing the correct implants is imperative.

In recent decades, the range of implants on the market has increased steadily. Several implant systems from different manufacturers are now available with anatomical, teardrop-shaped implants varying in height, width and projection, as well as round implants varying in diameter and projection. The sheer number of available implants and shapes might at first seem daunting, but as the chest wall shape and breast size among women in a uniform population usually do not vary greatly, a relatively small number of implants is required to solve most cases. In the authors’ experience, a majority of breast augmentations can be performed using fewer than 10 different available implants. However, given the great implant diversity, it is possible to find and fit an implant for virtually every patient’s features and desires. This allows the surgeon who is striving for perfection to challenge and solve both minor and more difficult cases involving breast and chest wall asymmetries in a way never possible before.4,5

Implant Selection

The process of selecting the correct breast implant can be described as being fairly simple in most cases, but a great challenge when managing a complete spectrum of patients seeking breast enhancement.

In the authors’ practice, breast implants containing highly cohesive silicone with a textured surface are used. Both anatomically shaped and round cohesive gels are incorporated in the authors’ matrix concept, based on volume distribution.

Most frequently used are the anatomical, teardrop-shaped implants.

In general, anatomical implants have their advantage in cases where a certain shape is more important than just added volume for thin patients, and for correction of breast asymmetries. The authors prefer textured implants with highly cohesive silicone gel, as these provide excellent control over the aesthetic result both in the short and long term. Furthermore, the risk of implant rupture, rippling9, bottoming out and visibility is low over time.

It is the authors’ strong belief that implants should be selected preoperatively, during the consultation, by the surgeon who is going to perform the surgery and follow-up the patient. The consultation should preferably take place in a peaceful environment, in front of a mirror, where the patient is given the opportunity to express her desires. Different implants (or sizers) can be tried on under a tight elastane T-shirt serving as a ‘second skin.’

The implant selection process involves the surgeon’s understanding of the patient’s expectations and a careful assessment of the patient’s chest wall and breasts. In order to understand what the patient is looking for, the surgeon must be attentive and may pose standard questions such as ‘Would you be satisfied if you were given the same breasts that you have today but a bit larger?’ and ‘Please explain to me where you think your breast is lacking volume?’

The surgeon then moves on to measuring the patient’s chest wall and breasts. The measurements should include the base width (BW), the nipple to inframammary fold (N-IMF) distance measured under maximum stretch, the intermammary distance, sternal notch to nipple distance (SN-N), a pinch test of the tissue in the breasts’ upper pole and a skin stretch test (Fig. 23.1AB).

image image

Fig. 23.1 A Measurements. B Base width is measured from fixed anatomical features; ‘No-touch’ zone to anterior axillary line (arrows).

The base width is by far the most important measurement during implant selection. By choosing an implant that is not too wide, respecting anatomical features and its tissue, the risk of future problems such as rippling, implant visibility, bottoming out or skin stretch is minimized. The SN-N distance provides a hint for the height of the implant. However, it is even more important to assess the patient’s posture and the projection of her upper chest wall. The pinch test directs the surgeon in the choice of whether or not to place the implant submuscularly. Sufficient tissue coverage is important so that the implants do not become visible in the long run. In the authors’ practice, highly cohesive implants seem to require more tissue coverage than less cohesive implants. This is because the authors believe that more cohesive implants, due to their firmness, might thin out the tissue over time. Highly cohesive implants should therefore more often be placed in the first instance submuscularly if there is not enough tissue coverage.

Given the great diversity of implant sizes and shapes, the implant selection process should be made as simple as possible and the young plastic surgeon should be able to solve the majority of cases after a minimum of practice.

Preoperative Planning and Marking

The women seeking breast enlargement at the authors’ practice, and probably throughout Sweden and Scandinavia in general, are, on average, fairly thin, with a limited amount of subcutaneous fat and breast tissue coverage. This has led the authors to use a subpectoral implant placement in most cases, in order to avoid possible long-term implant visibility in the upper pole of the breast. The preferred route of implant insertion is through an inframammary incision, as this gives a very high level of control during pocket dissection. Insertion via a periareolar incision is utilized mainly in combination with areolar mastopexy or if it is the specific desire of the patient. However, due to the risk of changes in areolar sensibility, interference with milk ducts and, thus, possible bacterial contamination of the implants, this route is not recommended.

Axillary approach with endoscope was abandoned by the senior author due to lack of precise control of the pocket dissection and, thus, of positioning of the implant.

Positioning of IMF Incision

In order to reach a successful outcome in any aesthetic surgical procedure, meticulous preoperative planning and marking are essential. Planning of the breast augmentation starts with implant selection during the initial consultation, as mentioned above. In this process, the characteristics of the patient’s chest wall and existing breasts are evaluated and measured. These measurements and the implant selection are double-checked in the morning on the day of surgery. To correctly perform the operation, a possible lowering of the inframammary fold, which decides the placement of the skin incision, now also has to be determined. All measurements, including the implant height and width, are marked on the patient’s thorax.

Correct positioning of the inframammary fold, involving a possible lowering of the existing fold, is crucial and depends on the N-IMF distance, the width of the implant and the patient’s tissue characteristics. It is important that the N-IMF distance and the lowering of the inframammary fold are always assessed under maximum skin stretch. The senior author’s experience, having met surgeons from all over the world, is that lowering of the inframammary fold is often performed with a great deal of hesitation, due to the difficulty in anticipating changes in breast shape over time.

The senior author Dr. Randquist has developed an easy and understandable system when calculating the positioning of the implant and IMF incision by controlled lowering of the inframammary fold as illustrated in Figure 23.2

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