What is Breast Augmentation?
Introduction
Breast enlargement is typically done through the placement of silicone breast implants tailored to meet a woman’s individual needs. Breast augmentation will depend on implant type, degree of enlargement required pocket, and body type. Modern breast augmentation is about volume distribution, not just the addition of volume.
The ability to obtain outstanding results consistently requires sound judgment, technical expertise, and meticulous attention to detail. However, with experience comes the realization that developing this skill is more challenging than it might appear. The most significant reason for this is the tremendous variability in the preoperative appearance of patients who present. Differences in the chest wall, breast size, nipple position, and skin elasticity are just a few variables that can significantly influence the 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 of a sound surgical strategy with exacting technical expertise in achieving a successful breast augmentation.
Preoperative Evaluation of Breast Augmentation
Patient History for Breast Augmentation
Before performing breast augmentation, a basic breast history is obtained that notes the changes that have taken place over time and documents the current condition of the breast—pertinent issues such as pregnancies and deliveries and breastfeeding.
A separate unique patient population is the postpartum breast augmentations and massive weight loss. The breast tissue atrophies and poor skin elasticity may accentuate implant visualization and rotation. It is constructive to ask patients how big their breasts became after breastfeeding, as this is often the aesthetic goal these women seek after breast augmentation.
A history of any previous breast biopsy or trauma is noted, and the location and the associated scar are documented. Long scars could potentially influence access incision choice.
Examination of the breast must be performed to assess for the presence of any discrete mass or another questionable area. Thorough palpation of the breast and axilla is performed with the patient lying supine, and the arm extended over the head to place the breast under tension, thus thinning the breast and facilitating the palpation of any suspicious masses. Should a mass be identified, a biopsy must be performed to document the nature of the lesion. 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 before performing a breast augmentation.
Indeed, a preoperative mammogram is highly recommended for any patient with either a personal history of any previous breast pathology or mass or any patient with a family history of breast cancer.
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 the patient should present for surgery at a stable weight before making decisions about implant size.
Preoperative, Assessment of Breast Augmentation
Physical Examination Before Breast Augmentation
The general appearance of the chest wall is noted with particular attention directed at any asymmetry that may be present in the shape or prominence of the ribs or sternum. When the essential structural support of the chest wall and, therefore, the breast is distorted or asymmetric, the effect on the shape of the breast after augmentation can be significant. Patients are counseled that the position and morphology of the breast on the chest wall cannot be altered with breast implant augmentation.
Similarly, using an extended tape measure, any asymmetry in the inferior aspect of the inframammary fold on each side can be measured and documented. When asymmetry in fold location is present, alteration in breast augmentation operative technique is often required to restore a sense of symmetry to this critical breast landmark.
Relevant Measurements before Breast Augmentation
These measurements document the breast and nipple-areola-complex (NAC) position on the chest wall. It triggers discussion between the patient and the surgeon about the proposed breast augmentation.
Intermammary distance
Patients present with the assumption that a breast augmentation will significantly enhance the degree to which the breasts will touch the midline, which is not valid in implant breast augmentation. This measurement reflects the distance between the most medial aspect of each breast as the breast is slightly pushed inward to accentuate this landmark.
NAC dimensions
It does identify those patients who present with an enlarged areola(resting areolar diameters of 5 cm); breast augmentation can often cause the areola to stretch to excessive dimensions. Concurrent nipple correction or mastopexy may augment the overall cosmesis. The width and length of the areolar diameter are measured under no tension and preferably before the areola is manipulated, so that contracture of the areolar smooth muscle fibers does not artificially constrict the areola.
NAC asymmetry
NAC asymmetry is a critical preoperative anatomic relationship to recognize and discuss with the patient as breast augmentation will distort it and the other contours of the breast. This observation can be demonstrated by laying an extended tape measure across the chest at the level of the nipple to visualize any asymmetry that might be present in the location of the NAC.
Surprisingly, patients are often unaware of their asymmetric NAC position. It can be helpful to have the patient stand in front of a mirror and visualize the degree of asymmetry before breast augmentation.
Clavicle to nipple
This distance is measured from the central aspect of the sternum down to the nipple. Typically, it ranges from 17 cm in a petite patient to 20 cm or more in very ptotic patients. The measurement is noted for both breasts, and it is common for the measured distance to vary significantly from one side. Causes for this include asymmetry in nipple position or breast size, or just as commonly, asymmetry in the clavicle’s position.
All these relationships are brought into focus by noting this measurement, which is essential as they can adversely influence the result if these asymmetries are not recognized before breast augmentation. For instance, if the same measured distance from the clavicle to the nipple on each side is used as the determinant of nipple position and the clavicles are asymmetric, then the resulting NAC position will also be asymmetric after breast augmentation.
Sternal notch to nipple
This distance is measured from the sternal notch to the nipple on each side. Because the sternal notch point is static, this measurement becomes a more accurate and consistent indicator of nipple location asymmetry, which can trigger appropriate discussions with the patient about how this asymmetry will be managed and what effect the asymmetry may have on the result after breast augmentation.
Inframammary fold to nipple under stretch.
This distance is measured from the inframammary fold up to the nipple with the lower pole breast skin placed under stretch. Comparing this measurement to the resting distance from the inframammary fold to the nipple provides a rough estimate regarding the elasticity of the breast’s lower pole soft tissue skin envelope.
Skin Envelope Characteristics for Breast Augmentation
The importance of this assessment relates to the projection of the implant that is ultimately chosen. For a tight skin envelope, a high-profile implant with enhanced projection may not fit under the skin envelope without prominent edges noted around the implant periphery after breast augmentation. Conversely, a moderate-profile implant may not effectively fill out the skin envelope for a loose skin envelope, and a high-profile implant may be a better option for breast augmentation.
Specifically, when the degree of stretch is 3 cm or more, a more projecting implant is indicated to fill out appropriately the lax skin envelope. When the degree of skin stretch is less than 3 cm, a highly projecting implant can create pressure on the implant secondary to the inelastic soft tissue cover, making a moderate profile implant a better choice for breast augmentation.
Breast height
The breast height must be measured when using anatomically shaped cohesive gel implants. These devices have specific vertical dimensions that must be accurately matched to this measurement patient to obtain the optimal result after breast augmentation.
Before any marking, an evaluation should identify the appropriate implant, the location of the incision, the implant pocket, asymmetries of the breast, chest wall, and nipple-areolar complex (NAC), and the inframammary fold (IMF). Evaluation of the soft-tissue coverage, including quality of the skin and breast tissue and amount of breast parenchyma present.
Preoperative markings are the most critical steps in achieving excellence in breast augmentation. The patient is marked in the upright standing position with the arms hanging loosely at the sides. The preoperative markings for breast augmentation create a roadmap for the planned procedure.
Patient Markings
Preoperative markings are the most critical steps in achieving excellence in breast augmentation. Breast Marking creates a roadmap for the planned procedure. The patient is marked in the upright standing position with the arms hanging loosely at the sides.
Patient Education and Informed Consent Form of Breast Augmentation
The first step in breast augmentation is the educational component; this step is the most critical aspect of the process and is frequently neglected by plastic surgeons. The surgeon and practice are responsible for dismantling misconceived notions and educating patients on the relationship between the breast tissue and implant selection.
Patients must have realistic expectations of cleavage, implant characteristics, and implant palpability. The surgeon and the patient can synergistically select the appropriate implant based on individualized tissue characteristics. Additionally, patients will accept their postoperative breast augmentation results.
Four key components have been outlined surgical approach:
- Comprehensive patient education and informed consent
- Tissue-based preoperative planning
- Refined surgical technique with rapid recovery
- Detailed postoperative education
Preoperative, Assessment of Breast Augmentation
Physical Examination Before Breast Augmentation
The general appearance of the chest wall is noted with particular attention directed at any asymmetry that may be present in the shape or prominence of the ribs or sternum. When the essential structural support of the chest wall and, therefore, the breast is distorted or asymmetric, the effect on the shape of the breast after augmentation can be significant. Patients are counseled that the position and morphology of the breast on the chest wall cannot be altered with breast implant augmentation.
Similarly, using an extended tape measure, any asymmetry in the inferior aspect of the inframammary fold on each side can be measured and documented. When asymmetry in fold location is present, alteration in breast augmentation operative technique is often required to restore a sense of symmetry to this critical breast landmark.
Relevant Measurements before Breast Augmentation
These measurements document the breast and nipple-areola-complex (NAC) position on the chest wall. It triggers discussion between the patient and the surgeon about the proposed breast augmentation.
Intermammary distance
Patients present with the assumption that a breast augmentation will significantly enhance the degree to which the breasts will touch the midline, which is not valid in implant breast augmentation. This measurement reflects the distance between the most medial aspect of each breast as the breast is slightly pushed inward to accentuate this landmark.
NAC dimensions
It does identify those patients who present with an enlarged areola(resting areolar diameters of 5 cm); breast augmentation can often cause the areola to stretch to excessive dimensions. Concurrent nipple correction or mastopexy may augment the overall cosmesis. The width and length of the areolar diameter are measured under no tension and preferably before the areola is manipulated, so that contracture of the areolar smooth muscle fibers does not artificially constrict the areola.
NAC asymmetry
NAC asymmetry is a critical preoperative anatomic relationship to recognize and discuss with the patient as breast augmentation will distort it and the other contours of the breast. This observation can be demonstrated by laying an extended tape measure across the chest at the level of the nipple to visualize any asymmetry that might be present in the location of the NAC.
Surprisingly, patients are often unaware of their asymmetric NAC position. It can be helpful to have the patient stand in front of a mirror and visualize the degree of asymmetry before breast augmentation.
Clavicle to nipple
This distance is measured from the central aspect of the sternum down to the nipple. Typically, it ranges from 17 cm in a petite patient to 20 cm or more in very ptotic patients. The measurement is noted for both breasts, and it is common for the measured distance to vary significantly from one side. Causes for this include asymmetry in nipple position or breast size, or just as commonly, asymmetry in the clavicle’s position.
All these relationships are brought into focus by noting this measurement, which is essential as they can adversely influence the result if these asymmetries are not recognized before breast augmentation. For instance, if the same measured distance from the clavicle to the nipple on each side is used as the determinant of nipple position and the clavicles are asymmetric, then the resulting NAC position will also be asymmetric after breast augmentation.
Sternal notch to nipple
This distance is measured from the sternal notch to the nipple on each side. Because the sternal notch point is static, this measurement becomes a more accurate and consistent indicator of nipple location asymmetry, which can trigger appropriate discussions with the patient about how this asymmetry will be managed and what effect the asymmetry may have on the result after breast augmentation.
Inframammary fold to nipple under stretch.
This distance is measured from the inframammary fold up to the nipple with the lower pole breast skin placed under stretch. Comparing this measurement to the resting distance from the inframammary fold to the nipple provides a rough estimate regarding the elasticity of the breast’s lower pole soft tissue skin envelope.
Skin Envelope Characteristics for Breast Augmentation
The importance of this assessment relates to the projection of the implant that is ultimately chosen. For a tight skin envelope, a high-profile implant with enhanced projection may not fit under the skin envelope without prominent edges noted around the implant periphery after breast augmentation. Conversely, a moderate-profile implant may not effectively fill out the skin envelope for a loose skin envelope, and a high-profile implant may be a better option for breast augmentation.
Specifically, when the degree of stretch is 3 cm or more, a more projecting implant is indicated to fill out appropriately the lax skin envelope. When the degree of skin stretch is less than 3 cm, a highly projecting implant can create pressure on the implant secondary to the inelastic soft tissue cover, making a moderate profile implant a better choice for breast augmentation.
Breast height
The breast height must be measured when using anatomically shaped cohesive gel implants. These devices have specific vertical dimensions that must be accurately matched to this measurement patient to obtain the optimal result after breast augmentation.
Before any marking, an evaluation should identify the appropriate implant, the location of the incision, the implant pocket, asymmetries of the breast, chest wall, and nipple-areolar complex (NAC), and the inframammary fold (IMF). Evaluation of the soft-tissue coverage, including quality of the skin and breast tissue and amount of breast parenchyma present.
Preoperative markings are the most critical steps in achieving excellence in breast augmentation. The patient is marked in the upright standing position with the arms hanging loosely at the sides. The preoperative markings for breast augmentation create a roadmap for the planned procedure.
Patient Markings
Preoperative markings are the most critical steps in achieving excellence in breast augmentation. Breast Marking creates a roadmap for the planned procedure. The patient is marked in the upright standing position with the arms hanging loosely at the sides.
Patient Education and Informed Consent Form of Breast Augmentation
The first step in breast augmentation is the educational component; this step is the most critical aspect of the process and is frequently neglected by plastic surgeons. The surgeon and practice are responsible for dismantling misconceived notions and educating patients on the relationship between the breast tissue and implant selection.
Patients must have realistic expectations of cleavage, implant characteristics, and implant palpability. The surgeon and the patient can synergistically select the appropriate implant based on individualized tissue characteristics. Additionally, patients will accept their postoperative breast augmentation results.
Four key components have been outlined surgical approach:
- Comprehensive patient education and informed consent
- Tissue-based preoperative planning
- Refined surgical technique with rapid recovery
- Detailed postoperative education
Photography of Breast Augmentation
An instrumental part of the breast examination and patient education is patient photography. Together, the surgeon and patient can identify any asymmetries; this discussion also allows the surgeon to reiterate that postoperative breasts will not be identical.
Furthermore, using photographs, the surgeon can outline essential concepts, including the likelihood of implant palpability, the rationale for implant pocket dissection and incision choice, the expectations of cleavage and IMF, and the ideal implant.
Intraoperative Breast Augmentation
Patient Positioning
Patients are placed on the operating room table in the supine position. The arms are secured to the arm board at 45_ to stabilize the patient in the upright position. This positioning allows the surgeon to more accurately assess the implant pocket and the redraping of the breast tissue overlying it.
Infiltration of Local Anesthetic
Before surgical preparation, 50 mL of a local anesthetic solution is injected per breast. Through access site along the IMF, in a fanning fashion throughout the breast tissue. These injections assist not only in operative hemostasis but also in the management of postoperative pain.
Surgical Preparation and Sterile Draping
After local infiltration, nipple shields (created by placing a small piece of Tegaderm over each nipple-areolar complex) provide a barrier against potential bacterial contamination. The patient is prepped with chlorhexidine and draped to provide a sterile field with the entire chest and bilateral breasts visible for assessment during the procedure. The sterile dressings must be secured to prevent disrupting the sterile field while placing the patient upright.
Incision Selection
Patients and plastic surgeons want the most inconspicuous incision. Therefore, I believe that scar location should be a low-priority issue when selecting an incision location. The inframammary incision is usually the preferred location to hide scars after breast augmentation.
Popular available incisions for breast augmentations include inframammary, periareolar, axillary, and peri-umbilical. Specific patient anatomy or implant choice may suggest an incisional approach; however, often, the chosen incision is patient/surgeon preference.
Myths have evolved regarding incision location in breast augmentation. The following are untrue statements regarding incision locations:
- The inframammary incision location is not an excellent choice for patients with minimal breast tissue.
- A shorter scar is always preferable to a longer scar.
- Incisions off the breast are always less noticeable than incisions on the breast.
- One incision or another best preserves breast sensation.
For many surgeons, the choice of incision occupies a vital marketing niche for their practice, allowing them to offer incisions they can tout as “hidden around the areola,” “no scar on the breast,” or “hidden in the crease underneath the breast.”
Patients frequently prioritize incision location above more critical decisions, including patient and surgeon preferences, anatomic considerations, and implant type and size. Patients who have an optimal result from breast augmentation rarely express any concern about the location of their scar, positively or negatively.
Inframammary Incision of Breast Augmentation
The inframammary incision is the most used, owing to its direct access and visualization of the pocket with the slightest injury to surrounding structures. Adequate incision length, care to avoid trauma to skin edges, and precise closure techniques produce equivalent quality scars in all current incision locations over a wide range of patient skin types.
Periareolar Incision of Breast Augmentation
The Periareolar incision is second to the inframammary fold incision. It is particularly in a patient who presents with tiny breasts with little to no inframammary fold.
The periareolar approach is optimally used in patients with an enlarged areola preoperatively ( 4 cm). Patients who present with a small areola of less than 3 cm diameter can have limited access for dissection of the pocket and insertion of the implant.
Trans-axillary Incision of Breast Augmentation
The transaxillary incision provides an access site to the breast, which heals with a well-hidden. This technique allows saline implants to be placed without difficulty; however, larger gel devices, textured devices, and anatomically shaped cohesive gel devices may prove challenging to insert without damaging the implant.
The most critical disadvantage is compromised accuracy in pocket dissection and the potential for bleeding that is difficult to control. Furthermore, it does not provide optimal exposure and control for correction of constricted lower pole breasts or glandular ptosis. Should future problems develop, such as capsular contracture or implant malposition, many patients will receive an additional scar on the breast when correcting the problem.
Umbilical Incision of Breast Augmentation
No other approach creates as much trauma to adjacent tissue as the umbilical approach, which requires surgeons to create two tunnels through abdominal soft tissues from the umbilicus to each breast. If bleeding occurs, it cannot be stopped other than with direct pressure, which increases the potential risk for hematoma development
The creation of permanent soft tissue distortion with visible grooving in the upper abdomen extending from the umbilicus to the breast can develop in trim patients because of the trocar passing through the thin subcutaneous layer. It must also be pointed out to the patient should future problems develop; patients will receive an additional scar on the breast.
Surgical Techniques of Breast Augmentation
Implant pocket location options currently include submammary, subfascial, dual plane, and submuscular pockets. Each pocket location has a unique set of potential benefits and tradeoffs.
The first step is to determine the ideal position of the inframammary fold. It is calculated from the nipple with the tissue placed on maximum stretch. The standard of 7 cm for a base width of 11 cm, 8 cm for a base width of 12 cm, and 9 cm for a base width of 13 cm produce an ideal aesthetic outcome.
Subglandular Pocket Plane of Breast Augmentation
The incision starts at the central portion of the pocket and is deepened to the superficial fascia level. The fibers are divided, and the underside of the breast is entered on the top of the muscle fascia. Superiorly directed dissection will create the subglandular plane to accommodate the implant. Blood vessels encountered are divided under a direct vision to provide hemostasis. Together with the action of the earlier local anesthesia, absolute hemostasis can be ensured.
Once the center pocket has been completed, the critical inferior and inferomedial limits of the pocket along the inframammary fold are carefully dissected free. Once the pocket has been finalized, it is rinsed with saline until it is clear and hemostasis is rechecked.
Dual Plane Pocket
As the incision is opened, the lateral margin of the pectoralis major muscle will be visualized. A cautery touch will make it contract in the upper chest. Using hand-switching monopolar forceps allows precise control of blood vessels. Muscle fibers are released carefully under direct vision until the pocket is dissected as planned. The cautery divides the muscle about 1 cm above the proposed inframammary fold. The space under the muscle can be opened under direct vision by dividing the loose fibers. Continue to the sternum but do not proceed up the sternum using a lighted retractor. The dissection is complete if the intention is to do a dual-plane type I by the muscle division.
As a result, the upper portion of the implant remains covered by the pectoralis major muscle, but the lower part of the device is in contact with the underside of the breast. Rinse with antibiotic solution, and recheck for bleeding.
If the goal is to do a dual-plane type II or type III, then now is the time to do a release between the pectoralis and the overlying gland. This release is gradual and incremental. The most crucial point is not to overdo it. The dual-plane maximizes coverage and support of the breast implant while eliminating virtually all distractors of submuscular placement, including animation deformities and Snoopy deformity.
However, a breast implant is placed under the pectoralis major muscle, which will be compressed when the muscle contracts leading to undesired breast animation. Moreover, the dual pocket plane is prone to implant malposition.
Implant Choice of Breast Augmentation
Since the design of implants offers round versus anatomically shaped, smooth versus textured surfaces, saline versus gel fill, different types of gel fill (i.e., cohesive gel), and implants of differing projections, choosing the ‘optimal’ implant for a specific patient can be a daunting challenge.
For example, 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. The native breast volume will mask any asymmetry, wrinkle, or mild malposition problem in these patients.
However, as patients become thinner or increasing degrees of ptosis, specific implant selection plays a more critical role. It 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.
Round versus Anatomic Implants in Breast Augmentation
Breast implants can be either round or anatomically shaped. Within both subsets, there are a wide variety of widths, heights, and projections. Of note, round implants are used in 95% of primary breast augmentations in the United States.
Indications for both round implants and anatomic implants are outlined as follows:
Round implants
- Desired augmented look
- Good soft tissue coverage/good basic breast shape
- Revision surgery
In trim patients, as there is less soft tissue to mask, the shape of the round implant may accentuate the contour of the upper pole of the breast to a fault and create an unnatural or ‘augmented’ breast appearance. Anatomic textured cohesive silicone gel implants can negate this tendency.
Anatomic implants
- Desiring a natural look with minimal or no breast tissue
- Shapeless breast or breast with poor soft tissue coverage
- Constricted lower pole or tuberous breast deformity
- Simple or complex asymmetry
Volume as the primary variable of Breast Augmentation
For experienced surgeons, using volume as the primary variable is a prevalent technique for implant selection. Once this decision is made, base diameter or projection must be chosen as the second variable. There is a fantastic range of incrementally increasing acceptable base diameters that can be selected for a given volume, whereas, for projection, there are only three choices. For these reasons, base diameter becomes the second variable, and projection is chosen third.
Optimal fill is an amount that recognizes and respects each patient’s tissue characteristics, balancing aesthetic considerations with the more important priorities of protecting and preserving the patient’s tissue over her lifetime and prioritizing optimal soft tissue coverage for the implants’ long-term.
Projection as the primary variable of Breast Augmentation
Choosing the correct projection is primarily determined by the capacity of the existing breast skin envelope to expand to accept the underlying implant.
Should this capacity be limited, it would be unwise to attempt to insert a high-profile implant under such a breast as the pressure exerted on the apex of the device could flatten the implant enough to create a rounded contour along the edges of the implant.
Implant insertion for Breast Augmentation
An occlusive drape is applied to cover the NAC. The surgical gloves are changed and washed in the antibiotic solution, and the implant is inserted into the pocket.
The chosen implant is opened and immediately covered with the antibiotic solution to prevent airborne surface contamination of the device. The antibiotic solution is splashed onto the implant and incision as the device is inserted to reduce friction and ease implant insertion.
The implant settles to the bottom of the pocket and conforms to the pressures the overlying soft tissue framework places on it.
Before incision closure, the patient should be placed upright to assess implant position, fold position, symmetry, and the optimal relationship between the implant and the overlying breast tissue. Any additional adjustments can be accomplished after the patient is replaced in the recumbent position.
Once the lower portion of the pocket is dissected free, it opens up into a loose areolar plane that dissects very quickly. The entire upper portion of the pocket is then developed from medial to lateral. Little blood loss should have been noted during this dissection, as each potential bleeding point is controlled immediately under the direct vision afforded by the inframammary fold incision
Once the pocket has been finalized, it is rinsed with saline until clear and hemostasis is rechecked.
Incision closure of Breast Augmentation
In general, if the IMF structure is well developed and stable, and has not been violated or lowered during the procedure, then reapproximation of the superficial fascia during closure is usually adequate.
However, when the fold is unstable from either inherent weakness in the fold structure or its disruption with fold lowering, closure should include stabilization of the fold structure. Thus, during the closure, special care must be taken so as not to injure the breast implants inadvertently.
The incision is closed in 3 layers: Scarpa fascia, deep dermis, and subcuticular. After final closure, a small occlusive dressing is applied to the incision, followed by a support cotton pad placement and the compression garment.
Postoperative Management after Breast Augmentation
The management of breast augmentation is variable among surgeons, and the choice of the implant itself can alter the postoperative protocols. Patients are on oral antibiotics for one week, and oral pain medication is gradually weaned during that same period.
Massage exercises begin as soon as they can be performed comfortably for smooth breast implants. It includes displacing the implant upward and downward in the pocket, crossing the arms and pulling the implants inward to create cleavage, and downward pressure on the implants to stretch the lower pole.
With both round and shaped implants, Implant massage is contraindicated, as the textured surface can irritate the pocket and potentially create serous fluid around the implant.
Limited arm movement other than the range of motion is recommended for the first week.
Patients can resume wearing regular bras after four weeks but should continue with sports bras during bedtime for an additional 2 to 4 weeks to limit lateral implant movement during pocket formation.
Vigorous activity is restricted for four weeks postoperatively. Return office visits are planned at six weeks, six months, and one year postoperatively.
What is New for Breast Augmentation
Composite Breast Augmentation (CBA): Using Implants and Fat
Despite half a century’s technological advances, the revision rate for breast prostheses remains high: 24 percent at four years and 36 percent at ten years. Revisions are performed for soft-tissue–related problems, not for failure related to the device per se. Soft-tissue problems include capsular contracture and inadequate overlying tissue causing visibility, a condition we define as “soft-tissue failure.”
By incorporating implant and fat, one may achieve the core volume projection of an implant complemented by the natural look and feel of fat. Asymmetry of soft-tissue volume can be addressed with equal-sized implants and differential fat transplantation.
Surgical Techniques
Type 1: Sub-glandular and Fat Overlay
Lipofilling is done subcutaneously in areas peripheral to the implant. Injection of the graft was performed using a 15-cm-long, 2mm-diameter spatula cannula, with retrograde strings of fat placed superficially in the subcutaneous tissue. On average, 55 ccs of fat were used to cover the implant in the superomedial transitional zones (55 ccs per breast, 110 ccs total).
Type 2: Dual Breast Implant and Fat Overlay
Two to three insertion sites were used to crosshatch fat deposition, with one site 1 cm inferior to the inframammary crease, another in the lateral pectoral region, and a third within the pigmented areola skin. The clinical endpoint resulted in a 1.5- to 2-cm soft-tissue thickening of the entire breast and surrounding transitional chest wall–implant interface. With the versatility of fat injections, implants can be placed in the sub-glandular plane, avoiding potential animation and lateral drift deformities.
Type 2: Revision Breast Implant Removal and Fat Overlay
Revision patients often presented with partial or complete soft-tissue failure and had subcutaneous breast tissue with visible implant contours. These patients underwent a program of pre-expansion to significantly increase the volume of the subcutaneous tissue overlying the breast implant.
SUMMARY
Our practice has adopted the philosophy that breast augmentation is not simply a surgical procedure but a process of four comprehensive steps. The surgeon and the patient must assume a mutual responsibility for selecting the implant based on breast dimensions. Furthermore, they must have a shared understanding of preoperative breast asymmetry and soft tissue limitations. I believe that future breast augmentation will rely more on combining the implant with fat.
