Breast – Anatomy
- Breast augmentation using implants has been an established procedure with a long historical record of safety.
- It is the most assured and quickest way to achieve the desired breast volume.
Suitable patients for breast implants includes individuals with :
- Mammary hypoplasia or Micromastia (small breast)
- Significant breast asymmetry
- Slight breast ptosis
- After breastfeeding some patients experience significant upper pole breast volume loss. A suitably size breast implants can provide some lifting effect and restoration of the upper pole volume loss.
- Post mastectomy reconstruction
- Nipple reduction
- Enlarged, drooping nipples are commonly encountered especially after breastfeeding. However, many patients often neglect the importance of a matching nipple size when considering breast augmentation.
- Nipple reduction is essential to achieve harmonious result.
- Mommy make-over – abdominoplasty combined with breast augmentation
- It is common for women after childbirth to experience both deflation in breast volume and lax abdominal skin with stretch marks. Mommy makeover which is a combination of breast augmentation (lift and implant) with abdominoplasty (tummy tuck) is a common request. This combination treatment provides significant rejuvenation effects to the entire torso.
- This is a surgery meant for patients with significant drooping of breast tissue. Breast implant can be inserted to provide additional volume and lifting effect.
WHAT DO I NEED TO CONSIDER WHEN UNDERGOING BREAST AUGMENTATION?
- Here are the some of the most important factors to be considered :
- Size of the Implant
- Type of Implant : Saline vs Silicone
- Shape of Implant
- Surface of Implant
- Surgical Incision
- Placement of Implant
- In Dr. Ng’s experience among Asian patients, the commonest request is for teardrop shaped silicone implants, sized between 200-300ml placed via inframammary incision into the sub-pectoral pocket.
1. SIZE OF THE IMPLANT
- The size of the implant has to be proportion to your body stature, height, chest circumference.
- It is also determined by width of breast base, amount of breast tissue and skin elasticity.
- Placing an excessively large implants will result in unnatural appearance if there is insufficient tissue coverage.
- During the consultation, you can try a variety of implant sizers to simulate the final outcome.
2. TYPE OF IMPLANT : SALINE VS SILICONE IMPLANTS
Silicone Breast Implant – Cohesive Gel
|Adjustment to body temperature|
- Adjust slowly (e.g. the implant remains cold for a longer duration after a swim)
- Leakage causes complete deflation but safely absorbable
- Leakage may cause local inflammation and granulomas, but much safer for modern cohesive gel implants
3. SHAPE OF IMPLANT
|Round/ Circular||Anatomical/ Teardrop|
- Dome shaped – less natural appearance
- Tear drop shape – more natural appearance
- Large variety of shapes based on different height and projections
- More options for incision
- Usually inframammary incision
4. BREAST IMPLANT – SURGICAL INCISIONS
Breast implant : Choice of Incisions
- Scar well-hidden within breast fold
- Scar at areolar margin – may result in hypertrophic scars
- Hidden in the armpit crease but visible when wearing sleeveless
- Well hidden in the umbilicus
|Accuracy of implant placement|
- Direct visualization of orientation of implant
- Best accuracy for all implant placement
- Reasonably accuracy of implant placement
- More difficult to ascertain the orientation of implant
- Least accurate placement of implant
|Limitations on implants|
- Limit choice of implant size if areolar diameter is < 3.5- 4 cm
- Difficulty with teardrop shape implant
- Suitable only for saline implant not for silicone implants
- Most popular approach for tear drop shape silicone implant
- May cut through breast tissue to allow implant placement
- Risk of nipple numbness
- Risk of skin numbness around armpits and upper arm
- Difficult to lower inframammary fold if needed
- Difficult and blind dissection
- High or asymmetrical implant placement
5. SURFACE OF IMPLANT
Polyurethane (PU) -covered implant – had very low contracture rates but has been withdrawn because of carcinogenic compound from PU breaks down (although at very low levels)
6. PLACEMENT OF IMPLANT
Breast implant – Sub-mammary placement
Breast implant – Sub-pectoral placement
|Placement||Implant underneath breast tissue, above pectoris major muscle – more anatomical||Implant underneath pectoralis muscles – less anatomical|
|Suitable Candidates||For patient with sufficient original breast tissue – result can be very natural||For patient with very little breast tissue –pectoralis major muscle provides additional coverage to camouflage edge of implant.|
|Natural Appearance||More natural appearance if there is sufficient breast parenchymal||Better appearance for those patients with very little breast parenchymal|
|Capsular Contracture||Higher risk||Lower risk|
|Nipple Sensation||Maybe affected||Not affected|
|Implant Size Limitation||Allow larger implant||Implant size limited by size of subpectoral pocket|
|Limitation of activity||Not likely||Chest muscles contraction may cause implant to shift laterally (“dancing breast”)|
|Recovery||Slightly less pain||Slightly more pain|
DESCRIPTION OF PROCEDURE
- Pre-operative sizing during consultation :
- Patient try multiple implant sizes to simulate the final outcome.
- Pre-operative screening includes: blood test and breast imaging (ultrasound, mammogram)
- In a typical surgery via inframammary incision :
- Pre-operative marking includes planning of the new inframammary fold and incision.
- Incision at new inframammary fold
- Dissection to create space either a sub-glandular or sub-pectoral pocket for implant placement.
- Insertion of implant.
- Meticulous wound closure in multiple layers.
- Support bra are worn immediately post-operatively.
Keypoints in Breast Implant Surgery :
- Accurate assessment of suitable implant size. The size of the implant has to be proportion to patient’s body stature, height, chest circumference. It is also determined by width of breast base, amount of breast tissue and skin elasticity.
- Accurate placement of the new inframammary fold.
- Most patients undergoing breast augmentation has insufficient breast tissue and tight skin envelop. The inframammary fold need to be lowered to accommodate the implant to avoid a high riding appearance.
- It is crucial to determine how much the inframammary fold to be recited based on the implant size and elasticity of native skin envelop.
- Accurate dissection of implant pocket :
- The size of the implant pocket determines the final appearance of the implant. Inadequately dissected pocket can cause rippling of the implant surface. Over dissection can result in implant displacement and synmastia (bilateral breast pocket communicating together with loss of cleavage).
- Dr Ng prefers general anaesthesia for greater patient comfort and safety.
- In order to create a sub-pectoral pocket for insertion of the implant the chest muscles need to be relaxed. This may compromise the patient’s breathing capability if done under deep sedation. General anaesthesia is safer because continuous oxygen delivery to the patient is ensured throughout the surgery.
WHAT TO EXPECT POST OPERATIVELY
- Home on the same day
- Medication includes : antibiotics, pain relief and medication to reduce swelling and bruising.
- Support bra to prevent implant from displacing laterally or riding high. Patient wears this bra for at least a month depending on the clinical outcome.
- Back to work (non-strenuous) within 2-3 days.
- Stitches (if any) are removed in about 2 weeks.
- Breast massage :
- Initiated from 2-3 weeks onwards to further improve the final appearance.
- Usually the direction of massage is downwards and inwards. This may differ depending on clinical status.
- Scar management :
- Scar massage to soften the scar
- Scar gel application to prevent scar thickening and reduce redness.
- Photo Therapy to further reduce pigmentation.
- Exercise :
- Light exercise can be restarted after 1 month.
- Avoid exercise that involved heavy usage of the pectoralis muscles for at least 2 -3 months.
- Appearance of breast :
- It is normal to expect swelling and tightness over the breast for the first 1-2 weeks. During this period of time the implant may feel more stiff and firm. As breast tissue covering the implant stretches over the next 2-3 months the implants will feel softer and more natural.
- Final appearance is usually achieved from 3 months onwards.
RISK AND COMPLICATION
- Bleeding and infection are uncommon.
- Infection is kept to minimal by the use of antibiotics, good surgical techniques and having the surgery done in a sterile operation room.
- Is a condition where both breast tissue where merged across the sternum due to over dissection during breast augmentation
- Implant rupture is very low risk due to modern day implants.
- Implant displacement
- Capsular contracture
- Breast reconstruction using implant post mastectomy due to breast cancer may be considered as a non-cosmetic procedure.
FREQUENTLY ASKED QUESTIONS
Is silicone breast implant safe?
- Silicone breast implant has been used for several decades for cosmetic as well as reconstructive purpose. It has a good safety record although it was temporarily banned for cosmetic usage in the United States for possible association with connective tissue disease. This was found to be untrue subsequently and banned was lifted.
What is the biggest implant for me?
- The size of the implant has to be proportion to patient’s body stature, height, chest circumference. It is also determined by width of breast base, amount of breast tissue and skin elasticity. Placing an excessively large implants will result in unnatural appearance if there is insufficient tissue coverage.
What is the smallest scar me ?
- In most cases, the scar range from 3.5 to 4.5 cm depending on the size of implant chosen. It would be unwise to place a very large implant through the narrowest incision – implant rupture during surgery is not unheard of. During the consultation I shall illustrate this point during our meeting.
- Through a very small incision, the dissection of implant pocket and the control of bleeding (haemostasis) is made much more difficult.
Can I achieve a natural cleavage after breast augmentation?
- During dissection of the implant pocket, it is conventional to keep about 3 cm width of central chest tissue intact. This is to prevent over dissection which can result in the breast pocket from both sides communicating with each other (synmastia). This is a very difficult complication to rectify.
Do I need to replace the implants after many years?
- The silicone implant theoretically can last indefinitely i.e. the silicone in the implant does not hardened over time. As long as there is no significant capsular contracture there is no need to replace the implant.
What is capsular contracture?
- The body naturally produce a thin membrane (capsule) around any implanted foreign objects this membrane normally remains thin and pliable. In some patients significance scarring occurs in the membrane in this capsule causing the whole construct to appear stiff and hardened (capsular contracture).
- The severity of capsular contracture has been classified by Baker (1980)
|BAKER CLASSIFICATION SYSTEM OF CAPSULAR CONTRACTURE|
|Grade I||No palpable capsule||The augmented breast feels as soft as an unoperated one.|
|Grade II||Minimal firmness||The breast is less soft and the implant can be palpated, but is not visible.|
|Grade III||Moderate firmness||The breast is harder, the implant can be palpated easily, and it (or distortion from it) can be seen.|
|Grade IV||Severe contracture||The breast is hard, tender, painful, and cold. Distortion is often marked.|
|Usually implant replacement is done for grade III to IV capsular contracture.|
Can I breastfeed after breast augmentation?
- Breast augmentation should not interfere with breastfeeding as long as milk ducts are not cut. Other than peri-areoalar incision there is very low chance of affecting breastfeeding.
Can I still do breast screening examinations?
- After breast augmentation cancer screening can still be done using ultrasound, mammography and MRI scan. There are special mammographic views (Eklund Displacement) available for better visualization after breast augmentation.