Breast Augmentation Introduction



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Lip Teh
January 2006

Breast Augmentation
Introduction

Very high patient satisfaction and has positive effect on self esteem , interpersonal relationships


Indications

Glandular hypomastia classified as



  1. developmental

  2. involutional


Pathophysiology

  • Developmental hypomastia is a deficiency of skin , sub-cut tissue and glandular tissue and hormones and genetics play a role in this

  • Involutional hypomastia which occurs in postpartum involves a deficiency of glandular tissue with an excess of skin and sub-cut tissue and glandular ptosis and pseudoptosis is common


Aesthetic of the breast (Bostwick)

Defines the aesthetics of the breast into two senses



  1. tactile

  2. visual

  1. The attractive and aesthetically pleasing breast is characterized by proper symmetry, flow, contour and proportion

  2. Tactile considerations are softness, smoothness and sensitivity esp. in the NAC

  3. Normal volume should range from 300-500g with more fullness lat and inf to the NA complex and a 45 degree lateral inclination

  4. Ideally strong fascial support allows the parenchyma to remain above the IMF


History

  • 1895 Czerny - transferred a lipoma from the pts back to the chest

  • 1953 First solid alloplastic materials - polyvinyl ether, PTFE and polyurethane. Complicated by severe local reactions, pain, hardness and distortion .

  • 1954 Longacre– used autogenous tissue dermis fat flap to augment the breast with disappointing results

  • 1961 Uchida - first report of injectable silicone. Complicated by pain and chronic inflammation and granulomas

  • 1962 Cronin and Gerow – introduced subglandular silicone gel, but capsular contactures were a problem

  • 1970 Ashley - ”Natural Y” prosthesis a silicone elastomer covered with a polyurethane foam(PUF) envelope with a silicon gel filler with marked reduction in contracture rate (1-2%) – later modified to be called the Meme implant

  • 1991 PUF implants later found to fragment causing foreign body reactions and possible link to tumourgenesis in animal and thus was withdrawn from the market

  • 1992 the FDA withdrew the silicone Gel from the market for cosmetic reconstruction due to concerns about autoimmune disease

  • now in the US saline implants are commonly used

  • textured implants were introduced and has been shown that the capsular of a textured in implant is thinner and collagen is less organized when compared with a smooth and a reduced capsular rate(to baker iii and iv from 21-60 % to 4 %-11% in micro-textured implants-Coleman et al



Patient evaluation

History

  • Size, symmetry of breasts

  • Breast lumps, nipple discharge and infections

  • Planning more children, breast feeding

  • General medical HX, meds, bleeding disorders allergy,

  • Previous breast operations

  • Family Hx of breast ca

  • self examinations and ecent mammography in age >40


Examination

Breast exam and axilla



  • Sit patient up

Note

  1. symmetry of breast mound and nipples( ie size, breast location, breast size, degree of ptosis, nipple location/inversion, inframammary line to nipple distance and notch to nipple distance)

  2. thickness of breast tissue, stretch marks

  3. relation of thorax length to trunk(long vs short waisted) shape of the thorax

  4. patient height

  5. measure chest wall and breast diameter

  6. skin evaluated for dermal integrity and stretch marks which are an indication of compromised skin integrity are noted

  7. note presence of tubular breasts

NB asymmetry due to rib flare, chest wall deformities (pectus excavatum, pectus carinatum, Polands ),postural habitus (scolisois) noted




Non Surgical breast expansion (Khouri PRS 2000)


  • brassiere-like system applying 20 mmHg of vacuum pressure to each breast

  • worn for 10 to 12 hours per day over a 10-week period to obtain an average increase of 98 percent over starting size.

  • The stable long-term increase in breast size, however, is 55 percent.


Planning for Surgery

  • Traditional method has been to use external filler in bra to estimated size desired but took no account of effects on breast

  • any implant larger than 350 mL induces predictable negative consequences over time on the tissues of the breast

  • After augmentation mammaplasty there is a progressive reduction in breast size due to breast parenchymal atrophy, skin atrophy and stretching; traction rippling and costal cartilage remodelling that eventually results in a concave shape of the ribs.

  • Tebbetts in 1994 introduced the biodimensional approach which defined a patient's desired result by dimensions

    • Method - the horizontal and vertical diameter of the existing breast and the desired projection is factored in and these three values are then entered into a table to calculate the correct implant size

    • Limitations:

  1. defines implant dimensions and volume that force patient tissues to an arbitrary result defined by patient and surgeon desires instead of quantitatively characterizing the patient's tissue dimensions and characteristics, and selecting an implant to fit the requirements and limitations of the tissues

  2. incorporates no system to limit volume and weight according to patient tissue characteristics, allowing patients and surgeons to define a desired result dimensionally and select implants that may be larger or more projecting than ideal for the patient's tissues, risking potential long-term negative tissue consequences that can be irreversible

  3. does not specifically address the number one priority in breast augmentation, that is, ensuring optimal soft-tissue coverage of the implant long-term

  4. does not address a critical third dimension, tissue stretch, which is a critical measurement to estimate volume required for optimal envelope fill.

  • Tebbetts (PRS Apr 2002) introduced the TEPID system to take into account of soft tissue characteristics

    • T = tissue characteristics of the breast; E = the envelope; P= parenchyma; I = implant; and D = dimensions and dynamics of the implant relative to the soft tissues

  • Tebbetts (PRS Dec 2005) then developed the High Five Decision Support Process to focus and simplify the TEPID system

    • prioritizes five critical decisions in breast augmentation and enables surgeons to address all preoperative assessment and operative planning decisions in breast augmentation in 5 minutes or less.

      1. Optimal soft-tissue coverage/pocket location for the implant.

        • This determines future risks of visible traction rippling, visible or palpable implant edges, and possible risks of excessive stretch or extrusion.

      2. Implant volume (weight).

        • This determines implant effects on tissues over time, risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy.

      3. Implant type, size, and dimensions.

        • This determines control over distribution of fill within the breast; adequacy of envelope fill; and risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy.

      4. Optimal location for the inframammary fold based on the width of the implant selected for augmentation.

        • This determines the position of the breast on the chest wall, the critical aesthetic relationship between breast width and nipple-to-fold distance, and distribution of fill (especially upper pole fill).

      5. Incision location.

        • This determines degree of trauma to adjacent soft tissues, exposure of implant to endogenous bacteria in the breast tissue, surgeon visibility and control, potential injury to adjacent neurovasculature, and potential postoperative morbidity or tradeoffs.


Soft-Tissue Coverage and Pocket Selection
Options:

      1. Prepectoral

      2. Subfascial

      3. Subpectoral




  • Tebbetts believes that umber one priority in aesthetic and reconstructive breast procedures utilizing any type of breast implant is to ensure optimal (not just adequate) soft-tissue coverage over all areas of the implant. The potential consequences of suboptimal coverage are often not apparent to surgeons and patients for several years following placement of the device (visible traction rippling and implant edge or shell visibility deformities)

  • based on quantified soft-tissue coverage to ensure optimal long-term coverage over the implant

  • If soft-tissue pinch thickness of the upper pole is less than 2.0 cm, choose a dual-plane or partial retropectoral pocket location to ensure optimal soft-tissue coverage.

  • If soft-tissue pinch thickness at the inframammary fold is less than 0.5 cm, should preserve intact pectoralis muscle origins along the inframammary fold for additional coverage, creating a partial retropectoral pocket (compared with a dual-plane pocket in which the surgeon divides pectoralis origins along the fold).




Pre-pectoral/subglandular

  • Subgladular best in those with adequate breast tissue to cover the implant

  • Indications

  1. ptosis and mild excess skin envelope

    1. more effectively restore breast shape and correct breast ptosis than submuscular implants.

  2. mild tubular breast

  3. active body builders with well developed pectoralis major

  • Contraindications

  1. irradiated breast

  2. avoid in thin breast tissue

  3. strong history of breast cancer

  • Method:

    • Blunt dissection: Blunt dissection in the subgland location prevents hematoma formation and damage to IMA perforators

    • Super pocket (saline implants): Originally pockets the same size of the implant were created but the result of the forces of wound contraction further reduced the size of the pocket distorting the implant. Thus now the pockets are created significantly larger than the implant and maintained as such by the patient with massaging. Small pocket still for textured implants.


Subfascial (Graf PRS 2003)

Advantages:



  1. avoids implant deformation or distortion seen in the retromuscular position

  2. leaving additional soft tissue support/cover between the implant and the skin

  3. minimizing implant edge prominence inherent to subglandular placement

  4. in an animal study, may decrease capsule formation and probably further capsular contraction (PRS Mar 2005)

  • May be approached transaxillary, inframammary and periareolar

  • Tebbetts argues that fascia is thin (0.1-0.5mm) and plane of dissection difficult


Sub muscular ( Dempsey and Latham 1968)

  • May be partially behind the pectoralis major muscle (partial retropectoral) or totally behind pectoralis major and serratus (total submuscular).

  • Advantages:


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