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Chapter 60 Clinical Decision-Making in Breast Surgery
BREAST SHAPES AND SIZES
Scars
Although many patients’ perception is that plastic surgery means no visible scars, in
reality that is not possible. Rather, our goals should be to keep the scars minimal in
length and as inconspicuous as possible as we enhance the breasts’ shape. There is
no question that shape is far more important than scars. I believe that shortening of
scars and maintenance of optimal shape are mutually attainable goals.
The following three women have had aesthetic breast surgery. They each demon-
strate ideal shape, appropriate size to match their bodies, and inconspicuous scars.
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AUGMENTATION
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Chapter 60 Clinical Decision-Making in Breast Surgery
MASTOPEXY
REDUCTION
2172
Part XI Breast Surgery
How do we control shape, symmetry, size, and scars? Symmetry and size are related
more to the surgeon’s judgment, artistic sense, and surgical skill than to operative
technique. When breast implants are placed, the shape of the breasts is largely de-
pendent on the dimensions, volume, and shape of the implant. Shape and scars, on
the other hand, are very much dependent on operative technique. Optimal breast
shape and minimal scars are possible through a variety of techniques.
Safety: The Fifth S
Breast aesthetics also consists of safety—not only of the patient, but also of the nipple-
areola complex. Knowledge of the arterial blood supply and venous drainage of the
breast, and specifically of the nipple-areola complex, is essential.
Breast Augmentation
Although the type of breast implants available may vary from one country to an-
other, the principles of implant selection remain the same. The most important de-
terminant of the aesthetic quality of the result is the size of the implant. Inappro-
priate size selection leads to problems with shape and the need for revision, especially
with saline implants.
Patient Evaluation for Breast Surgery
Skin
Width (BW)
– Quality
Thickness (BT)
– Quantity
Suprasternal notch-nipple distance (SSN-N)
Parenchyma
Nipple-inframammary fold distance (N-IMF)
– Fatty
– Fibrous
Skin-parenchyma relationship
– Tightly adherent
– Moderately adherent
– Loose
Detailed patient examination and careful physical measurements will guide the sur-
geon in selecting the appropriate implant to optimize results and minimize the need
for revisions. We must weigh the patient’s anatomic features and her desires for breast
size in selecting implants, taking into consideration available implant sizes and di-
mensions in light of our own experience and judgment.
The examination of the patient includes breast measurements and an assessment of
the breast parenchyma and skin, including the relationship of the skin to the un-
derlying breast tissue. All of these anatomic features will influence implant selection
as well as the choice of surgical approach and implant placement.
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Chapter 60 Clinical Decision-Making in Breast Surgery
I prefer a dimensional approach to implant selection rather than the volume ap-
proach, where the surgeon, through judgment or a desire to please the patient, se-
lects an arbitrary volume for the implant. The most important measurements in se-
lecting the implant are the breast width (BW) and breast thickness (BT). BT should
be measured in the upper pole. My preference is to measure it along the SSN-N line.
(Other measurements shown include AW, areolar width; MC-A, midclavicular to
areola; N-IMF, nipple to inframammary fold; and SSN-N, suprasternal notch to nip-
ple.) BW minus BT will indicate the maximum implant width for that breast. Charts
are available from all implant manufacturers clearly depicting the diameter, projec-
tion, and volume of their implants. Once the base diameter of the implant has been
decided on, projection and volume can be selected based on that diameter. If a mod-
erate profile implant would not accommodate the volume or projection desired for the
patient, a high profile implant may be selected that will allow more volume and pro-
jection with the same diameter. This dimensional approach to implant selection allows
maximal projection without exceeding the height and width limits of the breast.
Anatomical or shaped implants demand more precise and detailed measurements to
ensure that the appropriate shape, height, and projection are selected.
SSN-N
BW
MC-A
AW
N-IMF
BW
BT
N-IMF
A moderate profile implant is shown. With increasing volume, the implant extends
beyond the width of the breast without increasing projection.
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Part XI Breast Surgery
Smooth
round
implant
Smooth
round
high profile
implant
In contrast, a high profile implant increases projection with increasing volume with-
out extending beyond the width of the breast.
Implant Options
Implant options include the following:
Size
Shape
Shell
Filler
Breast implants are offered in a variety of sizes, shapes, shell surfaces, and filler ma-
terials. Size options include dimensions, width, height, and projection as well as fill
volume. Prefilled implants do not offer the flexibility of on-table volume adjustments;
however, most saline implants and double-lumen implants do offer this option.
The majority of available implants are round, with variations in projection. Stan-
dard or moderate profile implants project less than high profile ones. Anatomic-
shaped implants are gaining popularity for primary breast augmentation, especially
with the cohesive gel implants that are now available. Although currently most ana -
tomic implants are for breast reconstruction and round implants are for augmenta-
tion, anatomic implants may well become surgeons’ first choice for breast augmen-
tation, especially in thin women. Although the movement of round implants within
the pocket does not pose any risk of breast shape change, anatomic implants must
be positioned precisely, and any movement will lead to distortion of breast shape.
Most if not all currently available anatomic implants are textured to reduce this risk.
The surface of the implant may be smooth or textured. At one time, polyurethane-
covered implants were very popular in the United States, and in fact, led to the de-
velopment and popularity of the textured-surface implants. Polyurethane-covered
implants are currently available in some European and South American countries.
Although the polyurethane covering of the implants is textured in appearance, this
covering is biologically active, becoming incorporated into the surrounding capsule,
unlike the standard textured silicone surface. My preference with saline implants is a
smooth surface rather than textured, because I have found less visible and palpable
rippling as well as a lower implant failure rate with a smooth-surface implant.
Our current options for implant fillers are limited to saline and silicone gel. Other
materials have been investigated but have not proved to have any advantage over gel
or saline. Some, such as the soybean oil implants, have been withdrawn from the
market. Although the saline implant remains a popular option for breast augmen-
tation in the United States, gel-filled implants are preferred in most of the rest of the
world. A variety of cohesive gel–filled implants are available and under development,
and I believe gel-filled implants will become the filler of choice in the very near fu-
ture. The advantage of cohesive gel is that in the event of implant failure, the gel will
not migrate. The cohesive property also enhances the maintenance of shape in the
anatomic implant.
Although saline as a filler is completely biocompatible without any side effects in the
event of leakage, it falls far short of the ideal filler in terms of feel, consistency, and
pliability. It also appears to have a more deleterious effect on surrounding tissues in
terms of thinning and stretching of the skin envelope than its gel-filled counterparts.
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Chapter 60 Clinical Decision-Making in Breast Surgery
Implant Specifications and Location Options
Submuscular
Submuscular
Retromammary
Implant Options
(total)
(partial)
Retromammary
Subfascial
Shell
Smooth
Textured
Filler
Saline
Silicone gel
Shape
Round
Anatomic
Implant Location
Degree of effectiveness indicated by number of pluses.
Implant Placement
Incisions
Several incision sites are available to the surgeon, depending on the procedure and
patient characteristics:
Axillary
Periareolar
Transareolar
Inframammary
Umbilical
My preferred incision in a patient with an established fold is the inframammary in-
cision, which I will place below the preexisting crease; the distance below depends
on the dimensions of the selected implant. In a patient with no fold, I prefer the ax-
illary approach and will place the incision within the distalmost axillary crease.
I make the periareolar incision only in combination with mastopexy. I have no per-
sonal experience with the umbilical or transareolar approaches bisecting the nipple.
In general, I prefer not to involve the breast tissues, specifically the ducts, in per-
forming breast augmentation.
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Part XI Breast Surgery
Choosing the Best Option: Breast Augmentation Approaches
Breast
Characteristics
Axillary
Periareolar
Transareolar
Inframammary
Umbilical
Mammary Fold
Well-defined
Undefined
Areola
Size
Wide
Narrow
Color
Dark
Light
Patient Preference
Incision
Location
The options for implant placement include retromammary, retromammary subfas-
cial, partial subpectoral, and complete submuscular. I reserve complete submuscu-
lar implant coverage for breast reconstruction with implants. For breast augmenta-
tion, I choose between the retromammary and partial subpectoral position based
on the shape and thickness of the breast. However, the relationship of the skin to the
underlying parenchyma also plays a role in this decision, as would minimal ptosis.
In patients with minimal ptosis whose breasts are amenable to correction through
implant placement, I will opt for retromammary placement, provided the tissues are
thick enough. If they are not thick enough, I choose submuscular placement with
the dual plane approach.
All things being equal, I prefer retromammary placement of the implant above or
below the pectoral fascia. In this position the breasts have a more natural appear-
ance, and the distortion seen with pectoral contractions is eliminated. The main ad-
vantage to retromuscular placement is the extra thickness afforded by the pectoralis
muscle, which in thinner women will provide more adequate implant coverage, less-
ening the potential for visible, palpable rippling, particularly with saline implants.
In women with less than 2 cm of breast thickness, especially superiorly and medi-
ally, I prefer partial submuscular placement of the implant, whether saline or sili-
cone gel. I will only place saline-filled implants over the muscle if the breast thick-
ness is 3 cm or more.
Recently several reports have shown the benefits of subfascial placement of breast im-
plants. The pocket is made deep to the breast tissue, over the pectoralis major muscle,
but including the pectoral fascia. Proponents believe that inclusion of this thin fas-
cial layer will add further protection or tissue volume around the implant. However,
this fascia can be very thin, adding very little volume. It would be far better to in-
clude the entire 5 to 10 mm thickness of the pectoralis major muscle if deemed nec-
essary rather than the fascia.
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Chapter 60 Clinical Decision-Making in Breast Surgery
Tissue Characteristics and Implant Location Options
Tissue
Submuscular
Submuscular
Retromammary
Characteristics
(total)
(partial)
Retromammary
Subfascial
Skin
Normal elasticity
Nonelastic stretched
Breast Tissue Thickness
2 cm
2 cm
Ptosis
Ptotic
Nonptotic
Implant Location
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Part XI Breast Surgery
Conclusion
I always counsel any woman seeking breast augmentation that implants are not per-
manent, will eventually leak, and will have to be changed; that breast augmentation
is not maintenance free; that regular follow-up examinations are mandatory; and
that her first pair of implants will not be the last. In terms of size, I find that most
patients come in after having talked to friends, researched on the Internet, and made
up their minds as to their desired implant volume or bra size. It takes a lot of pa-
tience and skill to discuss these issues with patients and to reconcile their desires
with the reality of their chest dimensions and tissue characteristics. I emphasize that
inappropriately large implants, especially those filled with saline, will lead to seri-
ous long-term complications. I explain to them that a dimension-based implant se-
lection will match their breast size to the most appropriate implant, and the choice
of access incision and implant placement, subpectoral or retromammary, is also made
to match their physique and tissue characteristics.
Breast Reduction
The goals of breast reduction are twofold: aesthetic and functional. Most women
seeking breast reduction have symptoms related to the large size of the breast and
the impact that breast weight has on their lifestyle, and on their ability to work and
exercise. Symptoms include pain and discomfort in the neck, back, and shoulders;
shoulder grooving, excessive sweating, or frank intertrigo in the inframammary fold.
The ideal procedure should not only enhance the form of the breast but also relieve
the patient of these symptoms. A sufficient volume of breast tissue must be resected
to achieve these ends. Postoperative dissatisfaction with breast reduction is not lim-
ited to scars and shape—far too often the patient complains that her breasts were
not sufficiently reduced in weight or volume to relieve the symptoms. Although our
priority is the aesthetic result of the reduction, surgeons must not lose sight of the
patient’s goal: relief of symptoms as well as aesthetic improvement.
Aesthetic goals are to reduce and reshape the breast with the nipple-areola complex
in the appropriate position through minimal scars and with minimal risk of nipple-
areolar loss, delayed healing, or wound disruption. By far the most common cause
of dissatisfaction and even litigation after breast reduction is scarring. For years breast
reduction procedures, although resulting in volume reduction, resulted in poor breast
shape, nonprojecting square or wide breasts, and extensive scarring. More recently,
greater emphasis has been placed on improvement and maintenance of shape with
minimization of scars.
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Chapter 60 Clinical Decision-Making in Breast Surgery
This young woman, who underwent an infe-
rior pedicle Wise pattern breast reduction else-
where, was seen for evaluation of scars and
shape improvement. She demonstrates wide,
nonprojecting breasts that have bottomed out,
and extensive inframammary scarring that ex-
tends beyond the breast, across the midline,
and past the anterior axillary fold.
The typical long-term result is shown after a central pedicle Wise pattern breast re-
duction. Despite the pleasing appearance of the breasts, projection is moderate and
bottoming out is noted, especially on the left side.
The typical result after breast reduction using the superior pedicle vertical technique
demonstrates projecting breasts.
Side-by-side comparison emphasizes the difference in shape and projection.
A number of operative procedures are available for breast reduction with a variety
of pedicles to maintain the nipple and areola, a variety of techniques to shape the
breast, and varying lengths of incisions. There is a tendency to refer to breast oper-
ations by the resulting scar, such as periareolar, vertical, and inverted-T. These terms
should refer only to the scar and reflect the pattern of skin excision. Different pedicles
and shaping techniques can be performed through each of these incisions. The ap-
propriate way to refer to a particular technique for breast reduction should include
the pedicle, the breast-shaping method, and the resultant scar.
All breast reductions—regardless of pedicle selection, scar placement, or scar length—
entail four steps:
Incisions for access
Parenchymal resection
Breast reshaping
Management of excess skin
With the Wise pattern, all steps are performed through the preoperative markings,
affording the best exposure and the option for limitless skin excision. On the other
hand, the periareolar approach offers very limited exposure and skin excision. The
short-scar options fall in between.
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Part XI Breast Surgery
The short-scar superior pedicle or medial pedicle options narrow the base of the
breast, increase projection, and push the nipple upward, whereas the Wise pattern
central or inferior pedicle procedures widen the base, flatten the breast, and displace
the nipple downward. It is not the scar or the pedicle that defines the procedure or
the result. It is the tissues resected, the location in the breast where they are resected,
and how the breast is reshaped that define the result.
Liposuction-Only Breast Reduction
The ultimate short-scar technique, liposuction-only breast reduction, has a role in
breast reduction. Both ultrasound-assisted liposuction (UAL) and suction-assisted li-
posuction (SAL) have been successfully applied to reduce the volume of the breast.
Liposuction has also been advocated for correction of ptosis through skin contracture.
Although there is no question that liposuction will significantly alter the volume of
the breast, it has minimal effects in terms of reshaping and enhancing projection or
the appearance of the breast. However, it is relatively simple, fast, and safe with lit-
tle, if any, risk of nipple-areolar sensory changes or loss. It is best for individuals
who may not be able to tolerate a 3-hour breast reduction procedure and are not
concerned about improving breast shape. A small number of younger women with
large, nonptotic breasts and normal skin elasticity are also good candidates for this
technique.
Liposuction perhaps enjoys a wider role as an adjunct to breast reduction, especially
in recontouring the lateral part of the breast and the anterior axillary fold area.
SAL has proved safe and efficacious for breast reduction, and fears of tumor dis-
semination have proved to be unfounded when preoperative mammography has been
performed. However, concern regarding the safety of UAL within the female breast
is as yet unresolved.
Pedicles
A variety of pedicles have been described for breast reduction. Although all are essen -
tially safe and based on sound anatomic knowledge, some are more popular than oth-
ers. Each pedicle has its own advantages, disadvantages, and special indications. Each
surgeon has his or her preferred pedicle based on training and experience. Pedicle
selection is based on the technique and size of the breast. The most devastating lo-
cal complication of breast reduction is nipple-areolar loss. Familiarity with a pedicle
and its limitations will minimize such risks. Compromised circulation, as in a heavy
smoker, increases the risk of nipple-areolar loss, regardless of the pedicle chosen.
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Chapter 60 Clinical Decision-Making in Breast Surgery
The nipple-areola complex has an extensive blood supply radiating centrally from
the periphery. The blood supply is based on the perforators of the internal mammary
artery through the pectoralis major muscle, the perforators based on the intercostal
vessels, laterally and medially, and the external mammary artery. A variety of ped -
icles are based on these vessels.
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Part XI Breast Surgery
Anteromedial
intercostal
perforator
Internal
mammary
perforator
Second
internal
mammary
perforator
External
mammary
artery
Anterolateral
intercostal
perforator
Internal mammary perforator
Intercostal
artery
Anterolateral
intercostal
perforator
Pectoralis major muscle
Anteromedial
intercostal
perforators
Internal mammary artery
Sensory innervation of the nipple-areola complex after breast reduction depends not
only on the pedicle selected but more so on the degree of nipple displacement and
the volume of resection. With very large breasts, the incidence of postreduction
changes in nipple-areolar sensitivity is high regardless of the pedicle chosen. Breast-
feeding after breast reduction is more dependent on pedicle selection.
Pedicle Options
Pedicle options include the following:
Inferior
Central
Medial
Superior
Lateral, including septum-based
Combinations
Free nipple graft
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Chapter 60 Clinical Decision-Making in Breast Surgery
The central and inferior pedicles have been the most popular, especially in North
America. These pedicles are safe and can be applied equally to minimally, moder-
ately, and massively enlarged breasts. The vascular basis of these pedicles is the mus-
culocutaneous perforating branches of the internal mammary artery through the
pectoralis major muscle and intercostal perforating branches through the muscle.
These pedicles are reliable; however, the need to preserve and maintain central and
lower breast tissue may lead to postoperative bottoming out. Breast-feeding after re-
duction with the central and inferior pedicles is usually possible, and preservation
of nipple-areolar sensitivity with small to moderate reductions is possible.
Anteromedial
intercostal
perforator
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Part XI Breast Surgery
The medial pedicle has gained favor as a safe alternative to the superior pedicle for
short-scar vertical reductions. The pedicle is based on medial perforating branches
of the internal mammary artery through the pectoralis major muscle and intercostal
perforating branches. It is a reliable pedicle for minimally, moderately, and even mas-
sively enlarged breasts, allowing easier elevation and inset of the nipple-areola than
the superior pedicle. The medial pedicle allows resection of central and lower breast
tissue, which contributes to the minimization of bottoming out. Breast-feeding is
possible after reduction with the medial pedicle, and preservation of nipple-areolar
sensitivity is also possible.
The superior pedicle, popularized with the Lassus and Lejour vertical techniques, is
based on superior perforating branches of the internal mammary artery (most no-
tably the second perforating branch) through the pectoralis major muscle, perforat-
ing branches of the intercostal arteries, and branches of the external mammary artery.
It is a safe and reliable pedicle best suited for minimally and moderately enlarged
breasts where nipple-areolar elevation and inset are relatively straightforward. For a
Internal
mammary
perforator
Second
internal
mammary
perforator
External
mammary
artery
massively enlarged breast, the nipple and areola are carried on a long dermal ex-
tension. Nipple-areolar elevation and inset are not always easy and may require care-
ful liposuction of the pedicle base to inset the nipple-areolar complex. The superior
pedicle allows resection of the central and lower breast tissue, eliminating lower
breast volume, which contributes to bottoming out. It is less likely that the patient
will be able to breast-feed after the superior pedicle technique, especially with a der-
mal extension, than other techniques. Nipple-areolar sensory preservation is possible.
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Chapter 60 Clinical Decision-Making in Breast Surgery
The lateral pedicle based on the external mammary artery enjoys the same advan-
tages as the medial pedicle, but not equal popularity. Occasionally, in an extremely
ptotic breast, I will combine a superior central and even inferior pedicle to ensure
nipple-areolar safety. For truly gigantic breasts, extremely ptotic breasts, and in women
who are heavy smokers, the free nipple graft is a safe alternative. Although hypo -
pigmentation is a common problem, it would be preferable to total nipple-areolar
loss. Breast-feeding is possible after the lateral pedicle technique, and nipple-areolar
sensation is preserved. Obviously, with the free nipple graft there is little, if any,
chance of the ability to breast-feed or preservation of nipple-areolar sensation. The
septum-based pedicle is basically a modification of this lateral pedicle.
Breast-Shaping Techniques
The original Wise pattern technique, which was the mainstay of breast reduction for
many years, especially in North America, relied on the skin brassiere to maintain
shape. This inevitably led to the all too familiar wide, nonprojecting, bottomed out
appearance. We no longer rely on a skin brassiere to shape or maintain the shape of
the breast. Our priority now is to reduce the breast parenchyma, shape the new breast
tissue, and then manage the excess skin. I refer to this as shape and drape—that is,
shape the breast, drape the skin, and then manage the skin excess. Not only have
these recent advances improved breast shape, they have also yielded longer-lasting
results.
External
mammary
artery
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Part XI Breast Surgery
Breast-shaping techniques range from the internal mesh application advocated by
Sampaio Góes to a variety of parenchymal incision and suturing techniques, and to
the pectoral sling technique of Daniel, as popularized by Graf and Biggs.
My personal preference is the vertical scar superior pedicle technique described by
Lassus. Resection of the central and lower breast tissue removes the breast mass, and
the breast shaping is performed through suturing of the medial and lateral pillars.
This, in fact, is the basis of the breast shaping with the medial and lateral pedicle
short-scar techniques. The Daniel technique involves isolation of an inferiorly based
dermal-glandular flap of breast tissue, which is mobilized, passed through a pec-
toralis muscle loop, and sutured onto the chest wall. The loop provides stability for
this flap, which improves breast projection. The breast is further shaped through su-
turing of medial and lateral pillars. The illustrations show the Daniel method, as
popularized by Graf and Biggs.
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Chapter 60 Clinical Decision-Making in Breast Surgery
Medial pillar
Lateral pillar
Fascia of pectoralis major muscle
Medial pillar
Lateral pillar
Inferiorly based flap
with superior, medial,
and lateral borders
mobilized
Incision to mobilize
flap at inferior border
Mobilized flap
based on
chest wall
Bipedicle
pectoralis loop
3 cm
The ideal approach to breast reduction is to resect the excess volume, then shape
the breast, drape the skin, and finally deal with the redundant or excess skin. This
concept of shape and drape is best demonstrated in this woman, who underwent a
700 g reduction through a vertical incision with a superior pedicle. The redundant
or excess breast skin is clearly shown. Options for dealing with this include excision
and closure with a purse-string suture, a short horizontal T, or a J or L excision. Even
in such a large reduction, there is no need for a long horizontal component.
Skin
The most important factor in limiting incision length and scars in breast reduction
is not size or even nipple position; I believe it is skin quality and quantity. Short scars
and optimal breast shape are compatible and limited only by skin quality, skin quan-
tity, pedicle safety, and surgical experience. The inverted-T is still the standard in the
United States, and without question allows maximal skin removal and maximum
exposure to the breast parenchyma for shaping procedures. I believe its role should be
limited to skin excision only, and not used for breast shaping. The length and place-
ment of the scar in reduction and mastopexy should reflect the surgeon’s choice for
management of the excess skin. A number of the short-scar techniques, especially
those leaving only a periareolar scar, rely heavily on skin contraction as a way of
dealing with skin excess.
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Part XI Breast Surgery
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Chapter 60 Clinical Decision-Making in Breast Surgery
As stated previously, size is not the issue; skin redundancy and skin elasticity, man-
dating skin resection, are the ultimate arbiters of scar length. Although these three
women have breasts of differing sizes, they all have normal skin elasticity, a full breast
envelope, and skin that is firmly adherent to the underlying breast. It is not possible
to pinch the skin away from the breast parenchyma of any of the three women shown
above. Therefore they are all good candidates for breast reduction through limited
scars. They do not have skin laxity or an excessive amount of skin that cannot be
managed through limited scars.
In contrast, these three women, who also have different-sized breasts, are not the
best candidates for short-scar techniques because they demonstrate poor skin elas-
ticity, partially filled breast envelopes, and skin that is loosely adherent or nonad-
herent to the underlying breast tissue. The breast skin of any of these women can
easily be pulled away from the parenchyma by gentle pinching. In these women longer
scars will be needed, because they have poor-quality skin that will not redrape or
contract and must be resected.
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Part XI Breast Surgery
The incision options for dealing with excess skin include the following:
Periareolar
Vertical
Small T
J or L
Full-length inverted-T
As we progress down this list, we are able to remove increasingly larger amounts of
skin. The higher we remain on the list, the more we rely on skin redraping and con-
traction, two options not available with stretched, inelastic skin.
My concept of breast skin excision is three-dimensional: unidimensional refers to peri -
areolar skin removal; bidimensional includes a periareolar and a vertical component;
and tridimensional includes a periareolar, vertical, and horizontal component. The
horizontal component may include a short T, a J or L, or the long horizontal T.
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Chapter 60 Clinical Decision-Making in Breast Surgery
Periareolar scar—unidimensional skin removal to the level of the areola
Periareolar and vertical incision; bidimensional skin removal adds vertical skin take-out to the
periareolar component, leaving the typical vertical scar
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Part XI Breast Surgery
The longer horizontal incision allows maximal skin resection
The short horizontal-T tridimensional skin incision adds a third component of skin excision for a short
distance on each side of the meridian of the breast
J or L horizontal component added to the vertical and periareolar incision; tridimensional skin removal
provides the option of skin excision along the lateral side of the inframammary fold
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Chapter 60 Clinical Decision-Making in Breast Surgery
Conclusion
There has been considerable progress in breast reduction over the past two decades.
Through the efforts of our colleagues in Europe and South America, short-scar tech-
niques are slowly being accepted and adopted in North America. The concept of re-
ducing and reshaping the breast through minimal scars is sound and here to stay.
A variety of reliable pedicles are available to ensure nipple-areolar survival, and a
variety of suturing and shaping techniques are available to produce the desired breast
shape and projection. Although it is not essential, desirable, or even possible for a
surgeon to be intimately familiar with all of these options, it is important that the
surgeon be familiar with two or three approaches. In the final analysis, we will each
pick the pedicle-shaping technique and incisions with which we are familiar and that
in our hands produce consistently good results, with minimal morbidity and mini-
mal scarring acceptable to our patients while meeting their expectations.
The role of the quality and amount of excess skin in defining the length and placement
of scars in reduction and mastopexy has been discussed. Not only skin quality and skin
excess, but the relationship of the skin envelope to the breast, together with the qual-
ity and type of breast tissue (fat versus fibrous tissue), should be taken into account
when choosing the procedure. These same parameters also determine the quality and
longevity of the result.
The following three women had breast reductions of varying amounts: 300, 500,
and 1000 g per breast. A superior pedicle technique was used with a vertical scar.
All demonstrate size reduction, shape enhancement, and minimal scars.
Breast reduction: 300 g per breast
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Part XI Breast Surgery
Breast reduction: 500 g per breast
Breast reduction: 1000 g per breast
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Chapter 60 Clinical Decision-Making in Breast Surgery
Mastopexy
Mastopexy is not only one of the most difficult breast procedures, but perhaps one
of the more challenging of all aesthetic procedures. Patients have high expectations,
yet the quality of their tissues, gravity, and aging all conspire against the patient and
surgeon alike. A variety of procedures are available, with or without implants, to lift,
reshape, and resize the droopy breast. It is essential to thoroughly evaluate the pa-
tient and her breasts before selecting the appropriate technique.
In my practice the quality of the tissues not only guides me in selecting the appro-
priate procedure for each patient, but also enables me to predict the quality of the re-
sult so that I can better explain and demonstrate to the patient the anticipated result
and how long it will last.
Most patients seeking mastopexy want fuller, perkier, lifted breasts. Before examin-
ing the breasts, I try to establish whether the patient is happy with her present breast
volume and simply looking for a breast lift or whether she is seeking both volume
Choosing the Best Option: Breast Reduction Approaches
Traditional
Short
Longer
Full-Length
Breast
Horizontal
Horizontal
Horizontal
Characteristics
Periareolar
Vertical
T
J or L
T
T
Size of Reduction
500 g
500-1000 g
1000 g
Skin Elasticity
Normal
Inelastic
Skin Excess
Minimal
Moderate
Massive
Parenchyma
Firm and fibrous
Soft and fatty
Skin-Parenchyma
Relationship
Firmly adherent
Loosely adherent
Skin Excision Pattern and Final Scar
enhancement and a lift. If possible, it is best to undertake a mastopexy after the
woman has completed her family rather than between children.
Evaluation of the breasts includes grading of the ptosis. Currently the two classifi-
cations available are those of Lalardie and Regnault, glandular or cutaneous. The
Lalardie classification includes grades I through IV, based on nipple-areolar posi-
tion. Regnault’s classification, described in 1976, is more complicated but takes more
into account. Regnault’s classification defines the different degrees of breast ptosis
and facilitates evaluating the problem and planning the operation.
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Part XI Breast Surgery
Major ptosis: Nipple at lower breast contour; breast below inframammary fold
Moderate ptosis: Nipple below inframammary fold but above lower breast contour
Minor ptosis: Nipple at level of inframammary fold
Although such classifications are useful, not all women can be classified into each
of these categories. In addition, these classifications do not take into account the
quality and quantity of excess skin or the relationship of the skin to the underlying
gland. My preference is to evaluate the skin envelope and contents, the relationship
of the skin to the gland, and finally the nipple position.
Evaluation of the Ptotic Breast
To fully evaluate a patient’s ptotic breasts, the surgeon must consider the following:
Skin
Gland
Skin-gland relationship
Nipple position
In the skin I look for loss of elasticity, as evidenced by striae, dermal thickness, and
skin recoil. I also make a mental note of the excess skin to be resected. The breast
tissue is evaluated for shape, volume, and consistency: Is the breast mostly fibrous,
fatty, or a combination of the two? In terms of the skin-gland relationship, I assess
whether the envelope is full or empty. Is the skin adherent to the underlying tissues,
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Chapter 60 Clinical Decision-Making in Breast Surgery
Glandular ptosis: Nipple above inframammary fold/breast descended below fold
Pseudoptosis: Nipple higher above inframammary fold; gland hypoplastic
with some breast descended below fold
or hanging loosely around it? Skin quality and the skin-gland relationship are the
key factors in determining the appropriate procedure and the quality and longevity
of the result. Finally, I assess the displacement of the nipples and the degree of nipple
elevation that will be required.
Patient Profiles
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Part XI Breast Surgery
This young woman has full, large breasts. The skin has normal elasticity and recoil,
the gland is firm and fibrous, the envelope is full, tight, and firmly adherent to the
parenchyma. The skin cannot be pinched away from the breast tissue. Her nipples
are displaced moderately. A good result is anticipated in this woman regardless of
technique, because all of her tissue characteristics are favorable and she has more
than adequate breast volume.
This young woman has partially atrophic breasts; her skin has maintained some elas-
ticity and recoil. Her gland is soft and fibrofatty. Her skin envelope is half-full, loose,
and lightly adherent to the parenchyma, and the skin can be pinched away from the
breast tissue. Her nipples are moderately displaced. A good result is anticipated, but
the degree of projection will depend on the technique. I would certainly consider an
implant for this patient.
This middle-aged woman has deflated breasts. The skin has lost most of its elasticity
and recoil, the gland is loose and fibrous, and the skin is barely adherent to the
parenchyma. The skin can be pinched away for 2 or 3 cm from the breast tissue. Her
nipples are moderately displaced. A reasonably good result can be anticipated, but
given the quality of her skin, it will not be a long-lasting result, and the patient should
be warned about the possible need for early secondary procedures. An implant should
also be considered.
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Chapter 60 Clinical Decision-Making in Breast Surgery
This middle-aged woman has deflated, atrophic, and asymmetrical breasts. Skin elas-
ticity and recoil are minimal. The gland is soft and fibrous, and the skin envelope is
empty and barely adherent to the underlying parenchyma. The skin can easily be
pinched away several centimeters from the breast tissue. An average result may be
anticipated; however, the patient should be warned that it will not be a long-lasting
result and that a revision may be required sooner rather than later.
Goals of Mastopexy
The goals of mastopexy include the following:
Restoration of shape
Restoration of volume
Restoration of nipple-areolar position
2200
Part XI Breast Surgery
Restoration of Shape
The ideal result after mastopexy is a projecting breast with the nipple and areola at
the point of maximal breast projection. There should be breast volume above and
below the nipple-areola complex, more below than above. The breast should also be
appropriately positioned on the chest wall.
Restoration of Volume
Many women seeking mastopexy have postpartum involution and a deflated ap-
pearance. Although they are candidates for volume replacement with an implant,
they are surprised when the recommendation is made, because they feel that they
have adequate breast volume. During the initial evaluation, I tighten the breast skin
with my fingers to bring the nipple-areola complex to the appropriate position; this
demonstrates to the patient the anticipated breast volume, without an implant post-
operatively. While holding her skin, I ask her to look down at her breast and into a
mirror to preview this breast volume. Most patients who thought that they had ade -
quate breast volume in the ptotic stage are surprised that the breasts will look smaller
once the ptosis has been corrected. I also explain to patients who require an implant
that their results will be better in terms of projection and in all likelihood will last
longer with an implant. There is a small group of women whose minor degree of
ptosis may be corrected with an implant without any skin envelope adjustment.
Restoration of Nipple-Areolar Position
Restoration of nipple-areolar position is an integral part of the mastopexy, and care
should be taken to preserve the blood supply to and venous drainage from the nipple-
areola complex, especially if the mastopexy is combined with an implant.
Skin Removal and Mastopexy
As with a breast reduction, skin excision is planned according to the tridimensional
approach: periareolar, vertical, and horizontal planes. The skin incision is designed
to allow sufficient access to the breast tissue for reshaping, placement of an implant,
and removal of excess skin. It should be noted that inelastic, stretched skin with
striae, and a skin envelope that is poorly adherent to the underlying breast paren -
chyma will not redistribute or contract and must be excised.
Establishing Surgical Priorities
During the patient evaluation, I identify the predominating needs of the breast. If
volume deficiency is predominant, volume replacement is performed first and then
skin excision. If the predominant factor is skin excess rather than volume, the breast
is shaped and the excess skin resected. If volume deficiency and skin excess are equal
determining factors, volume adjustment is performed first, followed by skin removal.
Skin Removal and Incision Placement
Similar to excisions for reduction mammaplasty, skin removal for mastopexy is
planned to permit circumareolar, vertical, and, when necessary, horizontal excisions
and remolding of the breast to a more natural, uplifted, conical shape. This skin re-
moval should also allow repositioning of the nipple and areola and, if ptosis recurs,
additional corrections through the initial incisions. The incisions and skin excisions
are planned on a continuum from periareolar to circumareolar to vertical scars and
then to horizontal scars. With this approach, additional breast tissue can be excised
later.
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Chapter 60 Clinical Decision-Making in Breast Surgery
When the nipple-areola complex is low, requiring only a small degree of elevation
of 1 to 2 cm, an upper periareolar crescentic ellipse can be excised to elevate it. An
augmentation mammaplasty may be done through this incision, if needed, to en-
hance breast volume to produce an elevated nipple-areolar appearance.
This upper periareolar ellipse can be rotated when specific lateral or medial posi-
tioning of the nipple-areola complex is necessary to move it to a more aesthetic po-
sition on the breast.
A circumareolar skin excision with periareolar purse-string closure tightens the skin
minimally without elevating the areola. It is effective for patients with tubular breasts
with protuberant areolae and for patients with very large areolae and pseudoptosis
who are to have augmentation mammaplasty. Removal of breast skin leaves only a
central circular scar. The scar, however, tends to widen, and the nipple position is
minimally elevated. It can also result in unnatural central breast flatness and loss of
attractive central projection; however, an implant can minimize this flatness. Alter-
natively, breast shaping and internal mesh support, as advocated by Sampaio Góes,
can enhance shape and projection. A permanent circular suture in the skin periph-
ery, the round block technique, reduces final skin tension and produces a finer scar;
this approach extends the application of this technique to some patients with mod-
erate ptosis.
2202
Part XI Breast Surgery
In patients with glandular and minor ptosis, the circumareolar excision with a short
vertical ellipse tightens the skin and elevates the nipple-areola complex. Care must
be taken to avoid excessive tightness below the areola. This incision can be short-
ened, because the vertical component contributes primarily to close the defect from
the transposed nipple-areola complex. The vertical scar tends to shorten in the post-
operative period with scar contraction.
For moderate ptosis the circumareolar excision with a vertical and occasionally a
short horizontal ellipse, J or L excision, produces a short inframammary scar and
tightens the breast while shortening the inframammary distance. This approach is
best only when there is excess skin after vertical mammaplasty that will not redrape,
contract, and must be excised. Rather than the short horizontal, J or L excision,
I prefer to take up the skin excess through a purse-string suture.
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Chapter 60 Clinical Decision-Making in Breast Surgery
For patients with major ptosis and excessive amounts of inelastic skin, who need
maximal breast elevation, a vertical and horizontal excision provides effective breast
elevation, even though this approach produces a longer inframammary scar. How-
ever, I make every effort to avoid the horizontal component if possible.
Mastopexy Augmentation
Combining mastopexy with augmentation is even more challenging than mastopexy
alone. The goals of the two procedures are diametrically opposed. Mastopexy tight-
ens and lifts the breast, whereas an implant stretches and expands the tissues and
often displaces the breast downward. Opinions differ as to whether this operation
should be staged. My preference has always been a one-stage procedure in which the
implant is placed first, and then the patient is marked for the mastopexy on the table
during the operation. As with reduction and mastopexy the quality of the tissues,
including the skin, will guide me in selection of technique and the anticipated result.
Conclusion
Mastopexy is a challenging procedure; the results are not permanent, and early re-
operation may be required to produce the optimal result. A compromise must be
struck between the patient’s expectations and the realities of her tissue characteris-
tics. Careful evaluation of the breast volume, skin, and tissue characteristics is an es-
sential prerequisite for operative planning. The patient should be counseled about
the limitations and longevity of these procedures. Technique selection and skin ex-
cision patterns reflect the same principles as those discussed for breast reduction. If
an augmentation is planned, the breast volume should be adjusted first and then the
skin envelope.
2204
Part XI Breast Surgery
Choosing the Best Option: Mastopexy Approaches
Traditional
Short
Longer
Full-Length
Breast
Horizontal
Horizontal
Horizontal
Characteristics
Periareolar
Vertical
T
J or L
T
T
Nipple Displacement
Minimal
Moderate
Maximum
Skin Elasticity
Normal
Inelastic
Skin Excess
Minimal
Moderate
Massive
Parenchyma
Firm and fibrous
Soft and fatty
Skin-Parenchyma
Relationship
Firmly adherent
Loosely adherent
Skin Excision Pattern and Final Scar
Choosing the Right
Breast Implant
DENNIS C. HAMMOND
CHAPTER 61
2206
Part XI Breast Surgery
T
he original design for a breast implant was inspired by the observation that the
saline in a half-filled intravenous bag assumed a breastlike shape. From there
the first silicone gel breast implant was created, used, and subsequently reported by
Cronin and Gerow in 1963. Ever since this original description, attempts have been
made to engineer a better implant to improve the performance of these devices. As
a result, a wide variety of different types of implants are currently available for use in
aesthetic and reconstructive surgery of the breast. Despite the seeming complexity
associated with these many different types, there are only three design variables that
describe nearly every one of these devices: mandril shape, shell characteristics, and
filling material. Understanding how these three variables mix and match allows the
surgeon to better understand how these implants interact with the patient’s soft tis-
sue to produce the desired breast size and shape.
Construction
Mandril Shape
To understand how the shape of an implant can affect the subsequent shape of the
breast, it is helpful to understand how an implant is made.
A solid form, or mandril, is attached to a dipping rod to determine the three-di-
mensional shape of the outer shell of the implant. The surface of the mandril is coated
with silicone, either by dipping the mandril into a vat of liquid silicone or spraying
a fine mist of liquid silicone onto the mandril. Repeated applications or dips of sili-
cone, followed by short drying intervals, ultimately result in a thin layer of silicone
rubber coating the mandril.
Courtesy Mentor Corporation
Once the shell has dried completely, the dipping rod is unscrewed from the mandril
and a circular cut is made around the dipping rod attachment site. Using this as an en-
try point, the elastic shell is pulled off by stretching it around the edges of the man-
dril (left and center). Thus the basic shape of the shell is determined by the mandril
that made the implant. The appearance of the silicone shell is shown immediately
after removal from the mandril. The hole in the shell, created by cutting it free from
around the dipping rod, has yet to be patched (right).
2207
Chapter 61 Choosing the Right Breast Implant
Courtesy Mentor Corporation
Courtesy Mentor Corporation
Next, the defect in the shell is patched with a sep-
arate sheet of silicone sheeting to finish the process
and prepare the implant envelope for subsequent
filling with silicone gel.
Round Implants
For the first 30 years of implant use, the predominant shape incorporated into the
design of a breast implant was classified as round. This description is actually a mi-
nor misnomer: a “round” implant actually has a shaped aspect to its design. These
implants are symmetrical in the horizontal and vertical dimensions; however, the
projection tends to be less than the width or height of the device. Thus a round im-
plant is asymmetrically constructed and is therefore shaped. This minor nuance be-
comes important when considering the behavior of breast implants in situ with regard
to how the ultimate three-dimensional shape of the breast is created.
Anatomically Shaped Implants
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Part XI Breast Surgery
What has been traditionally called an “anatomically shaped” implant is an implant
shell that takes the shaped concept a step further, with the dimensions of the im-
plant being asymmetrically designed in the horizontal, vertical, and sagittal (projec-
tion) dimensions. Here, the implant height is typically longer than the width, and
the projection of the device gradually increases from the apex of the device down to
the lower third of the implant. As a result, these devices demonstrate a teardrop shape
designed to mimic the contour of a normal breast in the upight position.
Texture
The original silicone gel implants were constructed with a smooth surface. However,
in the early 1970s it was discovered that coating an implant with a layer of poly -
urethane foam resulted in a dramatic reduction in the rate of capsular contracture.
This resulted in part from a low-grade inflammatory giant cell response to the
polyurethane, creating an ultrathin, pliable, and highly convoluted capsule.
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Chapter 61 Choosing the Right Breast Implant
These images depict the polyurethane foam being pulled off a round gel implant,
demonstrating the thickness of the foam as well as the porous nature of the mate-
rial. The scanning electron micrograph image shows the polyurethane foam layer.
Note the interconnecting lattice network with the variation in the size of the pores.
Unfortunately, over 10 to 15 years, the foam completely degraded away, resulting in
cases of late capsular contracture around the now smooth-walled silicone gel im-
plant. In an attempt to mimic the effect of the polyurethane foam, texturing of the
surface of silicone gel implants was developed. To date, two basic textures are used
in the vast majority of silicone and saline implants: Biocell and Siltex.
Biocell
The Biocell surface (Allergan) is created by coating a tacky implant shell with salt
granules and letting the outer implant shell harden. By subsequently washing away the
salt granules, an open pore lattice network is created that leaves an aggressive tex-
ture on the surface of the implant. The stereoscopic view (left) demonstrates the Bio-
cell textured surface with its variably sized, squarish pores left after dissolution of
the salt granules from the surface. The scanning electron micrograph view (right)
demonstrates the relationship of the pores to the underlying elastomer shell.
2210
Part XI Breast Surgery
This texture can actually interact with the capsule that develops in a favorable man-
ner by causing the collagen fibrils of the capsule to become intertwined with the tex-
ture of the shell. Such ingrowth occurs much more commonly with tissue expanders
than with implants, because the outward force of the inflated expander tends to drive
the textured surface into the capsule. By interlocking the capsule with the textured
surface, two events occur. First, the device becomes immobile, a feature that is par-
ticularly useful when using anatomically shaped devices that must maintain the
proper orientation. Second, many surgeons think that the textured surface reduces
the rate of capsular contracture, similar to that with polyurethane foam. This latter
finding is somewhat controversial; several studies have failed to note a reduction in the
rate of capsular contracture associated with the use of textured implants.
Siltex
The Siltex surface (Mentor) is created by pressing a thin layer of polyurethane foam
into a thin tacky sheet of silicone. The sheet is then allowed to cure, and then is cut
and attached to an otherwise smooth implant shell. The scanning electron micro-
graph of the Siltex textured surface (left) demonstrates the imprint of the polyurethane
foam sheet left on the shell. A similar view is shown (right) that highlights the rela-
tionship of the texture to the remainder of the thickness of the shell.
This is a less-aggressive texture that does not demonstrate tissue ingrowth. Despite
this finding, rotation of an anatomically shaped Siltex textured implant is very un-
common, primarily because the rough texture exerts a “fingerprint” effect on the
surface of the implant, producing enough friction between the device and the cap-
sule to effectively hold the implant in position. As with the Biocell device, many stud-
ies have suggested a reduction in the rate of capsular contracture when this texture is
used, although again, the point remains somewhat controversial.
Fill
Although several alternative filling materials, such as hydrocolloid gel and peanut
oil, have been proposed over the years, the only two that have stood the test of time
have been saline and silicone gel. Saline has the obvious advantage of being readily
available, entirely physiologic, and inert, which affords a particular advantage when
a saline implant ruptures, because the saline is simply absorbed and excreted without
sequelae. The surgeon can fill the device during surgery; thus differential implant fill-
ing techniques can be employed to manage asymmetries in a very controlled fash-
ion. The disadvantage of saline relates to the feel of the implant that results, because
the low cohesivity of saline results in a fluidlike water-balloon effect on the implant
that can be seen and/or felt in thin patients.
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Chapter 61 Choosing the Right Breast Implant
However, silicone gel has much more inherent cohesivity, producing a softer, more
natural feel to the implant. The appearance of the less cohesive memory gel present
in standard textured and smooth round silicone gel implants is shown above. The
gel is less extensively cross-linked during curing, leading to a looser consistency to
the gel (left). The gel can also be structurally cross-linked to a greater degree to cre-
ate a firmer gel that is used to support the shell in anatomically shaped implants.
The appearance of the gel from an anatomically shaped cohesive gel device is shown
(right). Because of a greater degree of cross-linking of the silicone molecules, it has a
firmer consistency, which translates to better support for the anatomically constructed
shell. However, because these implants come prefilled, the volumes are limited to a
defined schedule of choices. If the implant ruptures, the gel remains in the periim-
plant space, and an operative procedure must be performed to remove the implant
material.
Design
Implant Shape
Taking the three design variables into consideration—mandril shape, shell charac-
teristics, and filling material—it is possible to combine them into a host of possible
implant designs. However, the predominant variable is the shape of the device. To
this end, two basic groups of implants are commonly used today: round or anatom-
ically shaped.
Round Implants
All round implants have a horizontal and vertical dimension that is symmetrical.
However, several different types of round implants are available that differ in pro-
jection. Most manufacturers offer round implants with three different projections
for a given volume. These are generally named using a system that designates them
as having a low, mid, and high projection or profile.
2212
Part XI Breast Surgery
Anteroposterior and lateral views are shown of a series of moderate, moderate plus,
and high profile implants, all with a 325 cc fill volume. It is important to realize that
for these devices with volume as the fixed variable, as the projection of the implant
increases, the base width of the device decreases. This has implications for how these
implants are used in specific patients. For instance, a patient with a tight skin enve-
lope and severe macromastia will not be able to tolerate a high projection or high
profile implant without creating tension at the apex of the device, resulting in a
rounding out of the periphery of the implant and possibly creating a prominent,
rounded contour at the breast periphery. In such cases a moderate profile implant is
a better option, because it will fit beneath the skin envelope without crowding the
space, creating a more comfortable relationship between the implant and the soft
tissue and a more aesthetic and natural result. Conversely, in a patient with a very
loose skin envelope, a low profile implant could nicely augment the base of the breast
but not adequately fill out the apex of the breast mound, creating an odd appear-
ance where the peripheral contours of the breast were filled out, with the apex of
the breast actually hanging off the front. In these instances, a high profile implant
would be a better choice, because it would more evenly fill out the loose and redun-
dant skin envelope.
Beyond issues related to projection, what the implant is filled with can dramatically
affect its performance. Because of their relatively low level of cohesivity, saline-filled
implants must be filled to a greater degree than silicone gel implants to perform safely;
an under-filled saline implant cannot support the upper pole of the device when it
is placed upright, resulting in collapse of the upper pole and wrinkling of the shell.
Such wrinkling results in sharp stress points in the shell that can weaken over time,
leading to rupture. For this reason, many surgeons slightly overfill saline implants to
prevent wrinkling and lengthen the life of the implant. One disadvantage of this over-
fill strategy is the more rounded contour of the overfilled round device. In thinner
patients, this rounded contour can distort the breast, creating an artificial, augmented
appearance. Filling the round implant with silicone gel is more easily tolerated by
the round implant shell. Here an underfill strategy can be used, because the wrin-
kles that form are much softer and place less stress on the implant shell. The wrin-
kles are also less likely to become visible through the skin envelope. This, together
with the overall softer feel of silicone gel–filled implants, makes these the implant
preferred by many surgeons.
Anatomic Implants: Design Variations
Shortly after the introduction of the silicone gel implant for breast augmentation, it
became clear to early practitioners that an anatomically shaped implant held at least
a theoretical advantage in creating a pleasing breast shape.
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Chapter 61 Choosing the Right Breast Implant
To this end, a shaped silicone implant was introduced that had five Dacron patches
attached to the back that held the implant in position and prevented rotation be-
cause they stimulated intense tissue ingrowth into the patches. Anteroposterior and
lateral views are shown of the original shaped silicone gel implant from the late
1960s. (Note the five Dacron patches attached to the back of the device.) From an
engineering standpoint, this was a sound implant design, and the merging of a shaped
2214
Part XI Breast Surgery
device with a means to hold the implant in the proper anatomic position is a valid
concept that applies to the use of anatomically shaped devices even today. However,
as can be seen in the example on p. 2213, severe capsular contracture was quite com-
mon with this particular early implant design, and the implant fell into disfavor.
Eventually a polyurethane foam–coated device with an anatomic shape called the
Replicon implant, developed by Surgitek, was introduced that again merged a tex-
tured surface that stimulated tissue ingrowth with an asymmetrical anatomically
shaped implant. This device was considered by many to be one of the most effective
breast implants ever designed. The device allowed better control of the shape of the
breast and, what is perhaps more important, remained soft over time, leading to one
of the lowest rates of capsular contracture ever reported. The biochemical effect of
the slow degradation of the polyurethane foam was somehow inhibitory to con-
tracture of the capsule. Unfortunately, the safety of this foam degradation process
was called into question in the early 1990s, because the byproducts of polyurethane
foam breakdown were thought by some to have carcinogenic potential. These con-
cerns were eventually dismissed as unfounded, but these types of devices were even-
tually removed from the market and have not yet become available again in the
United States.
With the development of textured silicone surfaces, once again there was an oppor-
tunity to apply an implant fixation method along with the anatomic concept for breast
implants, and over the years several different anatomic designs for both silicone and
saline have been introduced, as demonstrated in the lateral views shown next.
The Biocell (363 Allergan; Allergan, Inc., Irvine, CA) (left) and Siltex (Spectrum,
Mentor) (right) textured short height anatomically shaped saline implants were de-
veloped for both augmentation and reconstruction.
The Biocell textured full height anatomically shaped saline implant (163 Allergan)
(left) was thought to be better suited for reconstruction, because it could provide
better upper pole fill for the breast after mastectomy. The anatomically shaped Bio-
cell textured cohesive silicone gel implant (410 Allergan) (right) combined a variable
anatomic shape with a textured surface to provide a controlled result in both aug-
mentation and reconstruction.
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Chapter 61 Choosing the Right Breast Implant
A lateral view of an anatomically shaped Siltex textured cohesive silicone gel implant
(Contour Profile Gel [CPG], Mentor) is shown.
This side-by-side view shows a saline-filled implant placed upright compared with
an anatomically shaped cohesive gel CPG implant (Mentor). As a result of the sup-
port the cohesive gel provides to the anatomically shaped shell of the CPG, the im-
plant holds its shape when placed upright, whereas the saline device collapses in the
upper pole, leading to the possible formation of visible or palpable wrinkles.
Whatever the specific design, the concept remains the same; namely, by building an
anatomic teardrop shape into the implant, a better, more aesthetic breast shape can
be created through both aesthetic and reconstructive breast surgery.
Combination Implants
In an attempt to combine the advantage of saline volume adjustability with the softer
feel of silicone, manufacturers have developed a series of combination devices that
incorporate a dual-lumen concept. Generally, the outer lumen is constructed with a
silicone gel filler and the inner lumen is filled with saline. A remote valve passes
through the outer gel component to allow access to the inner saline portion.
2216
Part XI Breast Surgery
This anatomically shaped dual-chambered device has an inner saline bladder at-
tached to the lower pole. The fill tube enters the inner saline bladder through a valve
port built into a patch on the back of the implant.
The remote port is then buried under the skin and is accessed as needed to add vol-
ume to the overall implant. This device was introduced as a combination expander-
implant, because the external valve portion could be removed and a self-sealing mech-
anism would maintain the integrity of the device. In reconstructive cases, once the
needed volume had been added, the port and tubing could be removed with the pa-
tient under local anesthesia, with the device now also functioning as the final im-
plant.
This concept has also been explored for patients undergoing breast augmentation,
with volume adjustability allowing the patient to choose the final desired size by
adding saline as needed postoperatively, then eventually removing the remote port.
Although this is attractive in theory, such devices occupy only a small niche appli-
cability for the vast majority of surgeons performing aesthetic and reconstructive
breast surgery.
Rationale for Anatomically Shaped Implants
The rationale for using a shaped implant has been challenged by many in plastic sur-
gery, and the utility of a shaped device has been called into question. The counter-
argument is that round implants have worked quite well over the past 40 years, and
there is no need to invite the potential for implant rotation or to make a very straight-
forward operation more complex. This opinion is understandable, given the numer-
ous reports that have documented the excellent aesthetic results achieved with round
implants. However, these results must be interpreted in light of how these devices
are actually interacting with the surrounding soft tissue to create the final three-
dimensional breast shape. It is now clear that an underfilled silicone gel implant will
variably fold and wrinkle, depending on the characteristics of the soft tissue cover
overlying the device, as well as on the size of the pocket into which the implant is
placed. In most instances, these wrinkles are masked by the overlying soft tissue and
do not create a contour irregularity unless the soft tissue cover is very thin. How-
ever, when these implants are evaluated by imaging studies, the shape assumed by
the implant is variably and often markedly anatomic.
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Chapter 61 Choosing the Right Breast Implant
Recent data from an upright MRI scanner regarding implant shape have been ob-
tained to evaluate the shape of the breast and the implant in the upright position.
These images have documented the propensity of round implants to wrinkle and
demonstrate something other than a round shape under the influence of the overly-
ing soft tissue framework. This propensity for wrinkling can be seen with the lateral
view of the 325 cc smooth round moderate profile silicone gel implant (left). The
shell is wrinkled and the apex of the device of the device comes to a sharp point, cre-
ating a smooth takeoff from the chest wall in the upper portion of the breast.
325 cc smooth round moderate
profile silicone gel implant
310 cc smooth round high profile
saline implant filled to 350 cc
280 cc mid height low projection (321)
textured cohesive gel anatomic implant
Using upright MRI images, the relationship of the upper pole of the implant to the
overlying soft tissue can also be evaluated. When the implant can change shape in
the upper pole and become more angulated, deficiencies in the thickness of the soft
tissue cover can be tolerated without creating upper pole distortion. It is for this rea-
son that silicone gel implants are more versatile than saline implants, because a fixed
yet underfilled round silicone gel implant can more readily fold and assume a more
or less anatomic shape than a saline implant, which tends to retain a more rounded
configuration when properly filled. The upright MRI scan of a 310 cc smooth round
high profile saline implant is shown (p. 2217, center); the device has been filled to
350 cc. Note that the shell of the implant is completely filled and there are no wrinkles.
It does not take a significant leap of logic to then ask, if an implant assumes an
anatomic shape in situ, why not construct it to have an anatomic shape from the be-
ginning? Not only would the shape of the implant and therefore the breast be bet-
ter controlled, but also the wrinkling and whatever deleterious effect such wrinkles
would have on the shell of the implant, leading to potential weakening and rupture,
would be greatly minimized. Because the anatomic implant is constructed to assume
a teardrop shape, the in situ distorting forces across the top of the device are mini-
mized and wrinkling is prevented.
This argument has been confirmed again through upright MRI evaluation of breasts
augmented with cohesive gel anatomic implants, where wrinkling in the shell of the
device is minimal to none. In the MRI scan of a 280 cc mid height low projection
(321) textured cohesive anatomic silicone gel implant in an upright position (p. 2217,
right), the apex of the device remains contoured to create a smooth takeoff in the
upper pole of the breast. Additionally, the anatomic distribution of the gel along with
the absence of wrinkling in the outer shell can be seen.
One design feature of these types of devices relates to the consistency of the gel used
to fill the implant. If the gel has a greater density and is more cohesive, the magni-
tude of the distorting forces across the top of the device will be further minimized,
and the device will effectively create a teardrop shape without wrinkling. One way
to contrast the use of round versus shaped devices relates to this finding. With an un-
derfilled round gel implant that can fold and wrinkle according to the dictates of the
overlying soft tissue framework, it is the soft tissue that is shaping the implant to
create the final breast contour. This is a very versatile and effective way to use a breast
implant. However, with cohesive anatomic gel devices, it is most decidedly the firmer
anatomic implant that is shaping the breast. In this instance there is less room for
error, and each implant must be carefully measured and matched to each patient to
work effectively. This is why all anatomically shaped cohesive gel implants are man-
ufactured using a matrix strategy by which several different implant heights are
merged with an equal number of different projections. Within this framework, im-
plants of different dimensions and volumes are available for each cell of the matrix.
2218
Part XI Breast Surgery