All patients and surgeons interested in breast augmentation would love to know a technique that resulted in the ‘perfect breast augmentation’.
I recently reviewed a patient whose breasts I augmented 14 years ago, and both she and I could only describe them as perfect.
What makes them perfect?
Firstly, how they feel to the patient. Perfectly augmented breasts need to feel like normal breasts to the patient, as if there has been no surgery performed. This means that there should be no reminders of the implant. In particular the patient should have virtually invisible scars, no pain or lumps, with the implants soft and unable to be felt, blending imperceptibly with the natural breast. The implants should also move with the breast as it moves, and should not be stuck rigidly to the chest wall or move independently of the rest of the breast with muscle action.
Secondly, how they look. Perfectly augmented breasts should look symmetrical (within the bounds of normal variation), there should be no obvious scars when naked, in a bikini or a strapless dress, they should be age appropriately pert, and there should be one ‘breast mass’ on each side (not two, which would indicate an implant and original breast). They should also change their appearance as a natural breast does by hanging to a degree when naked, with minimal upper pole fullness (minimal volume sitting high above the nipple), yet being able to produce upper pole fullness in a natural manner in a push up bras, but without displaying any ridges.
Thirdly, how they feel to your partner.Perfectly augmented breasts feel like normal breasts, and even a trained hand may have difficulty identifying whether or not they have been augmented with implants.
Fourthly they should be stable over time(in other words their appearance and feel should not change with the passing of the years).
Fifthly, and perhaps most importantly, they need to be safe. The recent development of breast implant associated anaplastic large cell lymphoma associated with textured implants means textured implants probably should be avoided whenever possible.
‘Perfect breast augmentation’ technique
So what technique did I use for my patient with the ‘perfect breast augmentation’?
This can be broken down into general surgical technique: incision, type of implant, position of pocket (with respect to the pectoralis muscle or ‘pecs’), size of pocket and post operative care.
General surgical technique
General surgical technique includes operating in an accredited facility which is regularly audited for things such as infection control (please refer to my previous post”Important breast augmentation techniques to minimise the risk of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)”).
Operating with care and being as gentle as possible with the surrounding breast tissues also helps to minimise damage to your skin, subcutaneous tissues, muscle and breast. This minimises external and internal scarring, minimises the risk of infection (as bacteria breed more easily in damaged tissues) and capsular contracture (hardening of an implant resulting from the contraction of scar tissue surrounding the implant). Careful sealing of any bleeding blood vessels with diathermy also minimises the risk of a haematoma, which can lead to infection and capsular contracture. Good surgical technique also encompasses the 14 point plan discussed in my previous post (mentioned above).
Type of incision
There are several choices for the incision, but in my opinion only one good one. This is in the infra-mammary crease, which is the fold immediately below the breast, where it meets the chest wall. If the scar ends up in the inframammary crease then it is nearly always virtually invisible. The surgeon will have the best access to the breast implant pocket through an infra-mammary incision and thereforehas a much higher chance of achieving symmetry withminimal trauma and excellent control of bleeding. The infra-mammary incision also avoids cutting through any breast tissue, which minimises the risk of infection and protects all of the breast tissue for any future breast feeding. Another advantage is that the surgeon can preserve the join of the anterior and posterior breast capsules with Scarpa’s fascia. This is essential to maintaining a natural infra-mammary fold (the breast gland is contained in a capsule of fibrous connective tissue, which is basically a splitting of the superficial fascia in the subcutaneous layer, called Scarpa’s fascia. This will be considered in more detail in a further article).
Incisions around the nipple-areola are more likely to be seen naked, even if it is just by the patient in the bathroom after a shower. These incisions also involve cutting through breast tissue, which may decrease the chances of future breast feeding and increase risk of infection and capsular contractureand BIA-ALCL. The 14 point plan discussed in my previous postrecommends avoiding this incision.
Incisions in the armpit can be virtually invisible but not always. If there is any problem with scarring these incisions can be quite visible in bikinis or when dancing in a strapless dress. They are also a long way from the infra-mammary fold, making it difficult to achieve symmetry using a minimally traumatic technique. Armpits are also full of sweat glands that carry more bacteria than normal skin so the risk of infection (and subsequent BIR-ALCL) may be higher.
Type of implant
First is the saline versus silicone fill question. In my opinion saline implants feel and behave like a bag of water; I can always feel saline implants and thus I can never achieve the ‘perfect breast augmentation’ with them.
To my mind there is only one general type of silicone implant that should be used – smooth round silicone gel implants. The most important reason for this is that they are currently the only type of silicone implants that have been in use long enough to demonstrate that they are not associated with BIA-ALCL. Even before this disease was identified, I routinely used smooth implants because they are soft, difficult to feel (when capsular contracture has occurred), do not stick to the chest wall and are therefore mobile and move like natural breasts. I can always feel textured implants because they are harder with thicker envelopes than smooth implants and it’s for this reason that I can’t achieve the ‘perfect breast augmentation’with textured implants.
All smooth implants are round, but because the silicone flows more easily within them they adopt a ‘tear drop’ shape when standing, but then lose it when lying down. By contrast, ’tear drop’ shaped implants retain theirshape when lying down and to my eye this makes them more obvious when lying on the beach or in bed. Further, all tear drop implants are textured, meaning they carry the risk of BIA-ALCL.
Pocket position is a very important factor. To achieve the most natural result, the implant should be one with your normal breast tissue and move with it. To achieve this, the pocket should be made on top of Pectoralis muscle and the implant placed directly behind the breast capsule so that the implant and breast becomes a single unit, and moves as such. As soon as an implant is put underneath the muscle it becomes very difficult to have the breast and the implant act as a single unit. When under the muscle, the breast and implant are more likely to appear as two separate mounds, with the natural breast moving (and sometimes drooping) separately to the implant.With the implant under the muscle it can appear unnatural because the implant often becomes more rigidly fixed to the chest wall and doesn’t move. Alternatively the implant can attach to the pectoralis muscle itself and move with any muscle action, which also appears unnatural.
The only problem with this is the increased risk of capsular contracture of a smooth implant when placed above the muscle. This is what stops surgeons from being able to achieve the ‘perfect breast augmentation’ every time. However recent studies suggest that this increased risk may relate to increased bacterial contamination from the breast tissue, so if the surgeon is able to maintain the integrity of the posterior breast capsule with minimal trauma, then the risk of capsular contracture should be minimised. This is what surgeons are attempting to do with the ‘sub-fascial’ approach. In any case, the vast majority of patients do not develop significant capsular contracture when the implants are placed in front of the muscle and on this basis, I prefer to place the implants in front of the muscle when aiming for the ‘perfect breast augmentation’.
Pocket sizeis critical, no matter where the implant is placed. If the pocket size is too small, the implants will be rounded, high and hard, as if they have a capsular contracture from the start. If it is too large then the implants may fall out into the armpits, lack adequate cleavage or appear to join together in the midline (sym-mastia).
Good post operative care is vital. Avoiding strenuous activity for three weeks is critical to minimise the risk of bleeding and wound healing complications which might lead to infection, bad scarring, capsular contracture and perhaps BIA-ALCL. Wearing a supportive bra for the first 6 weeks also helps keep the implants in the correct position whilst healing. If advised (particularly with smooth implants in front of the muscle), a program of regular self massage can minimise the risk of capsular contracture.
Sadly, neither I nor other surgeon can achieve the ‘perfect breast augment’ result in every patient. What I have described is my technique which I believe achieves the best possible outcome in the vast majority of my patients. The main issue that this technique presents in a percentage of patients is capsular contracture. Many surgeons do not use this technique because of this fear, however I think that this approach is giving up on the ideal of the ‘perfect breast augmentation’ before the operation is even scheduled. Even by using textured implants and placing the implants under the muscle there is still a considerable risk of capsular contracture as well as extra problems, such as the risk of BIA -ALCL, the implant being separate to the breast, moving unnaturally with the muscle or being rigidly fixed to the chest wall.
I prefer to continue to aim for the ‘perfect breast augmentation’.