The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part XI  Breast Surgery
Contour Profile Gel
An alternative anatomically shaped cohesive gel implant called the Contour Profile
Gel (CPG), manufactured by Mentor, was introduced using the same matrix con-
cept (see p. 2215). Here the overall resistance to compression was graded as level 3,
with the standard gel of the traditional round implants called level 1, and mildly co-
hesive gel called level 2. Three different implant heights were offered including low,
mid, and full height, labeled 1, 2, and 3, respectively. Three different projections were
offered, including low, mid, and high projections again called 1, 2, and 3. The ma-
trix system was then organized using this numbering system. Since all these devices
were manufactured with type 3 cohesive gel, this whole matrix could be thought of
as the 300 series. With this in mind, a mid height low projection implant is called a
321, with 2 referring to height and 1 to projection. A 323 would be a midheight full
projection device. During the development of this matrix, it was realized that sev-
eral of the boxes in the matrix would create implants that had limited clinical ap-
plicability. Therefore to simplify the implant selection process, these outlier boxes
were removed, leaving a more refined selection of shape choices that removes the
more extreme shapes, leaving behind a more clinically relevant selection of implants.
CPG 332
CPG 321
CPG 322
CPG 323
CPG 312

Anatomic Implants: Saline
The anatomic concept has been likewise applied to saline implants by using an
anatomically shaped mandril to create the implant shell, which is then filled with
saline. The advantages of this implant design include use of the anatomic concept
and the ability to modify the volume of the device within a limited range of fill vol-
umes. However, the use of saline as the fill material remains a significant drawback;
as noted with round implants, saline has very limited cohesion and provides little
support to the implant shell. As a result, any tendency for the implant to be under-
filled results in wrinkling and loss of implant shape.
In practice, the implant actually requires a variable overfill strategy to prevent this
shape change with collapse of the upper pole of the implant when it is placed up-
right. Thus by overfilling the device, some of the anatomic shape of the device—in
particular, the contour of the upper pole—is lost, and the variably overfilled implant
actually can develop a mild bulge in the upper pole. Therefore, paradoxically, many
surgeons have noted that these devices, rather than affording control of the upper
pole of the breast, actually resulted in distortion of the upper pole. To some extent
this observation was responsible for many surgeons remaining skeptical about the
anatomic concept until the introduction of cohesive gel allowed the anatomically
shaped shell to be used more effectively.
Problematic upper pole control with anatomically shaped saline implants was more
common with full height devices. Shorter height implants were less prone to upper
pole distortion simply from a mechanical perspective, since there was less implant
to potentially overfill the upper pole of the breast, and many surgeons were able to use
these devices to good effect. No matter what the potential disadvantages may be,
anatomically shaped saline implants played an important role in the development of
the shaped implant concept. During the early 1990s, when there was a moratorium
on the use of silicone gel implants imposed by the FDA in the Unites States, the saline
implant was all that was available, and it was this experience that guided the sub-
sequent development of the current generation of anatomically shaped cohesive gel
implants.
Implant Selection
The goal in choosing a specific implant for a particular patient is to select a device
that will optimally complement the patient’s existing anatomy to create the most aes-
thetic result possible. To a certain extent, this goal can be influenced by the desires
of the patient regarding breast size and shape. To this end, a series of measurements
can be made preoperatively that directly guide implant selection.
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Chapter 61  Choosing the Right Breast Implant

2222
Part XI  Breast Surgery
Preoperative Measurements to Guide Implant Selection
Clavicle-to-Nipple Distance
The clavicle-to-nipple measurement provides a gauge to assess the degree of breast
ptosis. Although many other variables can influence this measurement, distances of
more than 19 to 20 cm indicate a low-riding nipple, and the surgeon may consider a
combination mastopexy and augmentation. Perhaps more useful is the observation
that this distance can potentially be different from side to side. Such asymmetry can
either result from an asymmetrical shoulder cant or clavicle position or from a true
asymmetry in nipple position. It is important to point out such asymmetries to the
patient ahead of time so she knows that these differences may well still be present
after the augmentation, or together with the surgeon she can consider procedures
designed to correct the asymmetry.
Sternal Notch-to-Nipple Distance
The distance from the sternal notch to the nipple, measured on both sides, is a truer
indicator of nipple-areola complex asymmetry, since the variables of shoulder cant
and clavicle position are removed.

2223
Chapter 61  Choosing the Right Breast Implant
Intermammary Distance
The intermammary distance is determined by gently translocating the breasts to-
gether medially in an attempt to reproduce the contour that will be created by an
implant. With this maneuver, some women will develop cleavage to the point where
the breasts actually touch. Others will maintain a variable distance between the
breasts. This assumes that the pocket dissection will not extend past the internal
mammary perforators and onto the thin presternal skin. It is important to discuss
this aspect of the breast augmentation result with the patient, because many women
will assume that their breasts will touch in the midline after the procedure. If the pre-
operative anatomy will not allow this, it must be pointed out ahead of time to avoid
any patient misconception.
Areolar Diameter
The horizontal width and height of the areola without tension is noted and used as
a guide to predict how big the areola could potentially become after an implant is
placed. If the size of the areola becomes excessive postoperatively, the quality of the
final result can be compromised. In these situations, the potential need for an areo-
lar reducing procedure can be discussed as part of the overall operative plan.

2224
Part XI  Breast Surgery
Inframammary Fold-to-Nipple Distance Without Stretch
The distance from the inframammary fold to the nipple serves as an indicator of the
amount of skin available to stretch over the implant. When this distance is short (less
than 5 cm), it is best to consider using a moderate (low) profile implant that will not
require a great deal of skin to wrap around the inferior pole of the device. When this
distance is excessive (more than 8 cm), a high profile implant to fill out the redun-
dant skin envelope with or without a mastopexy should be considered. For distances
between 5 and 8 cm, a moderate plus (medium) profile implant will usually suffice.
Inframammary Fold-to-Nipple Distance With Maximal Stretch
To assess the elasticity of the lower pole skin envelope, the distance from the infra-
mammary fold to the nipple is measure with the tissue under maximum stretch. As
with the static inframammary fold-to-nipple measurement, this information can af-
fect the choice of implant projection. When the lower pole skin stretches only 2 cm
or less, there is tight skin envelope and a lower profile implant may be the best choice.
When the skin stretches 3 cm or more, a higher profile device will more effectively
fill out the lower pole of the breast.

Breast Base Diameter
2225
Chapter 61  Choosing the Right Breast Implant
The base diameter of the chosen implant must fit comfortably within the confines
of the patient’s preexisting soft tissue framework. A linear caliper is used to estimate
the width of the breast that will result after the breast has been augmented. This
measurement extends from the medial border of the breast, just lateral to the loca-
tion of the internal mammary perforators, over to the proposed new lateral border
of the breast. This measurement is termed X.
Medial Breast Pinch Thickness
With a pair of skin fold thickness calipers, the horizontal skin fold thickness of the
medial breast is measured by pinching the skin together with the forefinger and
thumb of the left hand so that a horizontal skin fold is created. By dividing this mea -
surement in half, the thickness of the medial soft tissue layer that covers the medial
aspect of the implant can be determined. This measurement is termed Y.

Lateral Breast Pinch Thickness
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Part XI  Breast Surgery
Breast Implant Calculation
The base diameter of the implant that will optimally fit the patient can be selected
by subtracting the medial and lateral soft tissue thickness from the proposed breast
base diameter, or
X  (Y  Z)
This measurement simply represents the average base diameter that will comfortably
fit within the measured soft tissue framework. It is possible to underselect this mea -
surement by up to 1 cm to meet the needs of a patient who wants only a modest in-
crease in breast size. However, underselecting a base diameter by more than 1 cm
risks creating a contour deformity from incomplete filling of the soft tissue envelope
of the breast. Conversely, it is also possible to overselect this measurement by up to
2 cm, depending on the patient’s wishes. In this circumstance, the position of the in-
framammary fold will also likely have to be adjusted lower to accommodate the in-
creased dimensions of the device. In other words, there is a certain tolerance to the
measurement of the breast base diameter, and this dimension can be manipulated to
a certain extent to satisfy a specific goal.
Upper Pole Pinch Thickness
A similar measurement is made laterally
to determine the lateral soft tissue thick-
ness. This measurement is termed Z.
The soft tissue thickness of the upper pole of the breast can be assessed by pinching
the skin fold at the level at which the upper border of the implant will be located. If
the soft tissue cover measures 2 cm or more (or a 4 cm doubled over skin fold mea -

surement), the subglandular plane can be used for implant placement without risk
that the superior implant border will be visible. A measurement of less than 2 cm
may result in a visible implant shadow along the upper-inner quadrant of the breast
if the subglandular plane is used. Of course, other factors, such as implant shape,
volume, fill, and soft tissue elasticity can also have an impact.
Patient Desires
One of the most important elements of the preoperative evaluation process is to as-
sess very clearly what the patient wishes to achieve as far as the size and shape of
her breasts postoperatively. In the past, discussions based on cup size using the A, B,
C, D, DD sizing system have proved incomplete at best and inaccurate at worst. A
better way of communicating this would be based on the patient’s preexisting
anatomic limitations and how those limitations can affect the final result. To this
end, I have found the following classification system to be very useful for ensuring
that the result the patient and I have in mind is as similar as possible:
 Type 1: A small breast implant is used if the patient does not want the size of
her breast to be noticeably increased. Such patients are often simply seeking a
modest filling out of an underfilled and ptotic postpregnancy skin envelope. A
larger implant could easily be used, but the patient does not want that degree
of breast enlargement.
 Type 2: The patient’s overriding concern is for the breasts to be as large as pos-
sible, but not to the point at which the shape begins to appear unnatural. In
particular, the slope of the upper pole of the breast must be straight, with no
telltale bulging to suggest that an implant has been placed.
 Type 3: A larger implant is used to create an overly full upper pole and com-
plete filling of the skin envelope. When the patient wears a bathing suit or a
low-cut dress, it may be clear to the casual observer that the results appear
augmented.
 Type 4: The largest implant that can be inserted under the available soft tis-
sue framework is used, with no regard for the unnatural shape of the breast
that results.
Discussing this with the patient and attempting to understand what type of result
she desires can provide useful insight into the type of implant that can provide the
optimal result. This can minimize the reoperation rate for size change after initial
breast augmentation and increase patient satisfaction.
The evaluation parameters described in this section form the basis for the BodyLogic
implant selection system. The data sheets, required calipers, and implant selection
guides are commercially available from Mentor.
2227
Chapter 61  Choosing the Right Breast Implant

Indications
Round
Round implants continue to play a dominant role in breast augmentation, and for
good reason—an excellent result can be achieved in the vast majority of patients
with round gel or saline implants. Using the measurement parameters described ear-
lier, an appropriate round implant can be chosen to meet the needs of each patient by
matching the base diameter, volume, and projection in the best way possible to cre-
ate the desired result. Certain features concerning round implants bear emphasis,
however. When saline implants are used, the volume in the device must be at or even
slightly beyond the stated fill volume to prevent wrinkling in the implant shell. Thus
these devices tend to create a more rounded contour in the upper pole, and, when
this is taken to the extreme, can noticeably distort the breast. Conversely, round gel
implants are always variably underfilled and will fold and wrinkle once placed in the
pocket. The folds and wrinkles that form tend to be softer, with edges that are less
sharp than those that form with saline devices; therefore the wrinkles are better tol-
erated. These devices also have a softer feel to them. Because of this ability to fold
and conform to the overlying soft tissue framework, round gel implants offer a very
versatile option for breast augmentation; a full, natural shape is developed with less
chance for upper pole contour deformity.
Whether saline or gel, round devices continue to play an important role in the breast
augmentation practices of surgeons around the world.
Anatomically Shaped
It would not be an oversimplification to state that every breast augmentation patient
is a candidate for the use of an anatomically shaped cohesive gel breast implant. The
concept is that powerful, and the results can be that outstanding. The ability to di-
rectly control the contour of the breast by using the implant to create the desired
shape offers the surgeon control over the operation. With that as the basic premise,
one must then step back and evaluate the other variables and balance the potential
complications against the results obtained with round implants, sincere there are sev-
eral potential drawbacks associated with the use of cohesive anatomically shaped
gel implants.
2228
Part XI  Breast Surgery

2229
Chapter 61  Choosing the Right Breast Implant
Drawbacks to the Use of Anatomically Shaped Cohesive Gel Implants
ROTATION
It is self-evident that an anatomically shaped implant must remain in
the proper orientation to produce the desired shape. If the implant rotates, control
over the shape of the breast is lost, and the breast becomes distorted.
STIFFNESS
Although the cohesive gel supports the implant shell and helps create
the device’s shape, these implants have a stiffer feel than the more traditional round
gel implants. Some patients may find this firmer feel objectionable.
COMPLEXITY
The implant selection process and the operative technique are more
involved with anatomic devices than with round implants; therefore greater empha-
sis must be placed on accurate measurement of the patient and on more exacting
surgical technique. In short, there is less tolerance for inaccuracy when using shaped
devices.
COST
Anatomically shaped cohesive gel implants are more expensive than com-
parable round devices.
These variables, in particular the possibility of implant malposition with rotation,
must be weighed against the advantages of the shaped design. In general terms, if
the results obtained using a round device on one side and a cohesive shaped device on
the other were to be indistinguishable, it is a better option to use the round device
to avoid these potential complications. With that in mind, however, there are several
subsets of patients who are particularly good candidates for anatomically shaped
cohesive gel implants.
Suitable Candidates for Anatomically Shaped Cohesive Gel Implants
PATIENTS WITH HYPOMASTIA
In patients with small breasts in whom the implant
would provide 75% or more of the overall final breast volume, an anatomically
shaped device will provide better control over breast shape than a round device
would. In such patients, the ability to control the upper pole and maximize lower
pole projection allows the surgeon to create very aesthetic results, particularly when
used in the subpectoral position, where the muscle can be used to soften the pe-
Rotated
orientation
mark

2230
Part XI  Breast Surgery
ripheral upper pole contours. In these patients, using a cohesive gel anatomically
shaped device can create a more natural result for a given volume than a round im-
plant can. Reconstructive patients who have relatively thin mastectomy flaps and re-
visionary patients who have undergone multiple procedures with thinning of the soft
tissue framework of the breast can benefit from selection of a cohesive gel shaped
implant. As with primary hypomastia, the ability to directly shape the breast allows
the surgeon to more definitively control the quality of the aesthetic result.
This 32-year-old woman requested breast augmentation. Because of her significant
hypomastia, a textured anatomically shaped cohesive silicone gel implant was se-
lected to fill out the breast-skin envelope. She is shown 2 years after placement of
355 cc (321 CPG) mid height low profile textured cohesive anatomic silicone gel im-
plants in the subglandular plane. An overall aesthetic augmentation of the breast has
been achieved.
PATIENTS WITH PSEUDOPTOSIS
Patients who present with a properly positioned
nipple-areola complex but have ptosis of the lower pole with an excess of skin and
parenchyma in the lower pole are particularly good candidates for breast augmen-
tation using anatomically shaped cohesive gel implants. Because more of the gel is
located in the lower pole of the anatomic implant, a more proportional filling of the
lower pole of the breast results from its use and this can provide results superior
those obtained with round devices.

This 44-year-old woman requested breast augmentation to correct her pseudopto-
sis. Textured anatomically shaped cohesive gel implants were chosen to fill out the
lower poles of her breasts. She is shown 2 years after placement of 321 CPG mid
height low profile textured cohesive anatomic silicone gel implants in the subglan-
dular plane. Aesthetic augmentation of the lower poles of the breast has been achieved
without creating any distortion or excessive fullness in the upper poles of the breasts.
Patient Request
The safety profile associated with anatomically shaped cohesive gel breast implants
is impressive. Perhaps no other implant has provided such outstanding aesthetic re-
sults with fewer complications. For this reason, many patients who are knowledge-
able about implant selection often request information about these devices. At this
writing, these implants are still available only as part of an FDA-sponsored study.
Once they do become available for general use, the popularity of these devices is
likely to increase significantly.
Concluding Thoughts
The overriding goal in choosing an implant for use in aesthetic and reconstructive
breast surgery is to pick a device that will complement the patient’s existing anatomy
and provide the best aesthetic result possible. By thoughtfully combining the various
choices in shape, fill, and texture, implants appropriate for each patient can be selected
that will maximize the quality of the aesthetic result and minimize complications.
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Chapter 61  Choosing the Right Breast Implant

Clinical Caveats
 The patient’s desires should be assessed and discussed preoperatively regarding
size to avoid patient dissatisfaction.
 A selection system based on the patient’s anatomy rather than on cup size is prefer-
able.
 A repeatable measuring technique must be developed to enhance consistency.
 Base diameter, volume, and projection are combined to optimize implant selection.
 When possible, the bigger of two implants should be chosen when both will fit
the soft tissue framework.
2232
Part XI  Breast Surgery
Annotated Bibliography
Brand KG. Foam-covered mammary implants. Clin Plast Surg 15:533-539, 1988.
This reference is one of the first reports in the literature documenting the performance of
polyurethane-coated implants.
Coleman DJ, Foo IT, Shapre DT. Textured or smooth implants for breast augmentation? A
prospective controlled trial. Br J Plast Surg 44:444-448, 1991.
This is a classic article documenting the controversies regarding whether or not textur-
ing of breast implants provides any clinical benefit.
Cunningham B. The Mentor study on contour profile silicone gel MemoryGel breast im-
plants. Plast Reconstr Surg 120(7 Suppl 1):S33-S39, 2007.
This is one of the first reports in the literature on the results obtained using the newer
types of anatomically shaped cohesive gel implants.
Suggested Readings
Caffee HH, Peters CR. Textured vs. smooth implants: a controlled randomized trial. Plast
Surg Forum 14:248, 1991.
Cronin TD, Gerow FJ. Augmentation mammaplasty: a new “natural feel” prosthesis. Ex-
cerpta Med Internat Congr Series 66:41, 1963.
Handel N, Silverstein MJ, Jensen A, et al. Comparative experience with smooth and
polyurethane breast implants using the Kaplan-Meier method of survival analysis. Plast
Reconstr Surg 88:475-481, 1991.
McCurdy JA. Relationships between spherical fibrous capsular contracture and mammary
prosthesis type: a comparison of smooth and textured implants. Am J Cosmet Surg 7:235-
239, 1990.

Breast Augmentation

GLYN JONES
CHAPTER 62

B
reast augmentation is one of the most popular aesthetic surgery procedures
performed in the United States today. Each year more than 250,000 women
elect to have their breasts enlarged, despite unresolved questions about implants and
long-term problems such as capsular contracture. Typically performed to enhance the
size of normal but small to moderate-sized breasts, this operation can also help to re-
store balance to asymmetrically sized breasts. Although breast augmentation is a pro-
cedure with a high level of patient satisfaction, it is less routine than its description
would suggest. Critical decisions concerning the choice of implant, surgical approach,
and implant placement are essential to ensuring a satisfactory result. Even with metic-
ulous surgical technique, the operation is dependent on the design and efficacy of
the implantable device and the body’s reaction to this foreign material. Capsular con-
tracture remains the most persistent and troubling of potential complications as-
sociated with these devices. As a result, creating a long-lasting, soft, and natural-
appearing augmented breast continues to challenge the surgeon’s skill and ingenuity.
Evolution of Technique
The introduction of the silicone breast implant in 1963 marked the beginning of
breast augmentation as we know it today. Since its inception, this operation has
evolved with the development of new implantable devices with improved shell and
filler technology to enhance patient outcomes and to provide surgeons with a range
of treatment options. The popularity of this operation declined with the breast im-
plant controversy of the early 1990s, when the FDA restricted access to breast im-
plants filled with silicone gel because of fears about complications and possible links
to disease. These fears have largely waned over time as new scientific studies and clin-
ical trials have provided considerable information about the safety and efficacy of
these devices. Demand for breast augmentation today is even stronger than it was
before the controversy arose. However, restrictions placed on silicone gel implants
by the FDA have served to substantially limit implant availability in the United States.
The search for the ideal implantable device has long shaped the evolution of this op-
eration. The quest is for a device that is soft, natural, long-lasting, containing a
biodegradable filler, and radiolucent. The filling used is an important factor in ob-
taining this ideal. Early breast implants were filled with silicone gel. Experience with
these implants revealed that capsular contracture was a possible complication, which
led surgeons to develop saline-filled implants as a possible alternative. Although
saline-filled devices reduced capsular contracture to some extent, the incidence of
contracture remained frustratingly high. The quest for alternative fillers continues to
2234
Part XI  Breast Surgery

this day. Implants with lipid fillers have been tried but abandoned. Although they
were radiolucent and allowed improved visualization during mammography, they
were not biodegradable. Furthermore, reports of granulomas and a percutaneous
rancid odor made them unacceptable. While surgeons in the United States were deal-
ing with FDA restrictions on implant usage, the search for alternative fillers was on-
going outside the United States. Several companies developed cohesive silicone gel
implants for use elsewhere in the world. The first generation of these cohesive gel de-
vices was very stiff; however, newer cohesive gel fillers have a softer, more natural
feel and are now the primary implant choice of surgeons in most countries outside the
United States. The FDA has lifted its ban on silicone gel–filled implants for cosmetic
breast augmentation in the United States; these devices are now widely used in this
country and account for a substantial percentage of the devices inserted for breast
augmentation. Cohesive form-stable gel devices have not been approved by the FDA
for general usage, but it is hoped that they soon will be.
The shape and texture of implant surfaces have also evolved over time. Early im-
plants were round and smooth. Over time, to reduce the incidence of capsular con-
tracture, different surface coatings and textures were developed. Polyurethane-coated
implants produced a dramatic drop in the rates of early capsular contracture. Con-
tractures were reduced by the inflammatory response that was induced when
polyurethane foam came into contact with tissue, as well as by the large surface area
of the resulting capsule over the convoluted surface of a foam shell. Unfortunately,
as the polyurethane foam degraded, it exposed the underlying smooth gel implant
core, leading to a slow rise in capsular contracture formation beyond 10 years after
insertion. Favorable reports on the softness and performance of polyurethane-
covered implants, which are no longer available in the United States, combined with
studies of the relationship of physical surface properties to biological reactivity of
the implants, led to the development of the textured-surface breast implant in 1987,
which mimicked the foam surface of polyurethane. This stippled texturing had some
limited benefit, although it was never as effective as polyurethane. It was also noted
that the density of the surface texturing affected its ability to adhere to the tissues;
the denser or deeper the texturing, the greater the adhesion. Some surgeons believe
this texturing has been beneficial in reducing capsular contracture; however, the ad-
dition of texturing has also resulted in thickening of the implant wall, with increased
palpability and visible rippling. Although these features have detracted from the ad-
vantages of texturing, the new surfaces have also facilitated the development of re-
alistically shaped implants, which have become popular in recent years. These
anatomically shaped devices provide greater flexibility in breast shaping, but rota-
tion of the devices may cause unsightly deformation if the pocket is too large; more
aggressive texturing may limit the problem of implant rotation.
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Chapter 62  Breast Augmentation

Surgical approaches and planes for breast augmentation have also evolved over time.
Initially, breast augmentation operations were performed through an inframammary
incision accessing the subglandular plane for gel implant insertion. The inframam-
mary subglandular approach gave way to total submuscular placement to reduce
capsular contracture and implant visibility. Total submuscular coverage has in turn
yielded to a trend toward biplanar placement in which the implant is partially sub-
muscular and partially subglandular in its lower pole. Although both of these goals
were achieved to some extent, there has been an interesting swing back toward sub-
glandular placement to achieve better breast shape.
The inframammary approach remains the most common augmentation approach
used worldwide, followed by the periareolar approach. Transaxillary augmentation
was popularized in 1973, but many surgeons abandoned the technique when prob-
lems arose related to implant malposition, asymmetry of the inframammary creases,
and control of hemostasis from a remote-access site. The technique was resurrected
at Emory University in 1993 when endoscopic approaches made more precise dis-
section and implant placement possible. Endoscopy also paved the way for the de-
velopment of the transumbilical approach to breast augmentation (the TUBA pro-
cedure). Although this technique is not popular, some surgeons have achieved pleasing
results with it. Initial problems with the use of the implant as a pocket expander that
resulted in voiding of the implant warranty led the pioneers of this technique to ad-
vocate the use of a balloon expander or temporary sizer to create the pocket, with
subsequent permanent implant insertion at the end of the dissection. This has led to
wider acceptance of the technique.
Advantages and Disadvantages
Breast augmentation is an operation that has a high degree of patient acceptance. It
offers definite advantages for patients who seek larger breasts or correction of breast
asymmetries. It can produce enhanced breast shape, increased cleavage, some breast
lift in individuals with early ptosis, and balance for patients with constricted or tu-
bular breasts. It can also improve a patient’s body image and even make her clothes
fit better. Breast augmentation has no negative impact on breast-feeding ability, no
proven causal relationship with systemic illness, and no link to cancer. In fact, studies
have found that breast augmentation may contribute to earlier cancer detection in
augmented patients when compared with the unaugmented population.
The major disadvantage of breast augmentation is the significant risk for the devel-
opment of capsular contracture as well as the possibility that some revision surgery
will be required in the future to replace the implants, because implants are not life-
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Part XI  Breast Surgery

2237
Chapter 62  Breast Augmentation
time devices. Reoperation may also be required to address breast distortion and asym-
metry that may occur as capsular contracture develops.
Other implant-related problems that may develop include implant rupture, with de-
flation, leakage, wrinkling, and possible palpability of the implants. The fact that
breast implants feel cooler than natural breast tissue, especially in thin, small-breasted
women, is also a negative for some patients. Finally, implants may obscure breast tis-
sue, making it more difficult to identify breast problems on mammograms and re-
quiring special views to more effectively image a woman’s breast tissue.
Indications and Contraindications
Breast augmentation is indicated under the following circumstances:
 To augment the breasts in women with hypomastia
 To provide a mastopexy effect in women with mild to moderate ptosis
 To provide symmetry in women with developmental anomalies of the breast
(for example, Poland’s syndrome and constricted breast deformity)
 To provide symmetry in women undergoing breast reconstruction
 To provide upper pole fullness in women with volume loss after pregnancy or
massive weight loss, who require both mastopexy and augmentation
The following are contraindications for breast augmentation:
 Women with body dysmorphic disorder and other psychiatrically unstable
patients
 Women hoping to salvage a marriage or relationship or to find a husband by
having bigger breasts
 Women with collagen vascular disease (these individuals should be advised
against breast augmentation in the current legal climate, even though there is
no proven cause-and-effect relationship between collagen vascular disease and
breast implants)
 Women with severe fibrocystic changes, ductal hyperplasia, and/or atypia whose
breasts are difficult to image well or in whom there is a high risk of breast can-
cer (implants in these women make mammographic screening even more un-
reliable and may be relatively contraindicated)
 Women under 18 years of age should be discouraged from having augmenta-
tion, because they may not appreciate the long-term implications of implan-
tation of a foreign device
 Women who want the procedure in response to spousal, parental, or peer pres-
sure to have the procedure

Pertinent Anatomy
2238
Part XI  Breast Surgery
Deltoid muscle
Tail of Spence
Pectoralis major muscle
Latissimus dorsi muscle
Serratus anterior muscle
Rectus abdominis muscle
External oblique muscle
The female breast sits on the pectoralis major muscle overlying the second through
the seventh ribs. The nipple is situated at the midclavicular line over the fourth rib
in a youthful, nonptotic breast. The tail of Spence extends up toward the axilla over
the inferolateral border of the pectoralis major muscle and merges with axillary floor
fat. The intercostobrachial nerve crosses the axillary floor in its course to the medial
arm and may be at risk during transaxillary dissection.
The breast parenchyma is divided into lobules like the segments of an orange, each
segment having its own set of draining ducts that terminate in the nipple. This sep-
aration is only apparent on ductography.

2239
Chapter 62  Breast Augmentation
Internal
mammary perforator
External mammary
artery
Anterolateral
intercostal perforator
Second internal
mammary perforator
Anteromedial
intercostal perforator
Internal mammary artery
Intercostal artery
Pectoralis major muscle
Anteromedial
intercostal perforators
Anterolateral
intercostal perforator
Internal mammary perforator
The blood supply to the breast consists of a complex interlacing system of vessels
arising from the internal mammary perforators, the cutaneous branches of the in-
tercostal vessels, the thoracoacromial vessels, and the lateral thoracic vessels, together
with a small contribution from the crossing branch to the serratus anterior from the
thoracodorsal system.

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Part XI  Breast Surgery
Subclavian artery
Musculocutaneous nerve
Thoracoacromial artery
Pectoralis major muscle
Deltoid muscle
Biceps brachii muscle
Coracobrachialis muscle
Median nerve
Axillary artery
Medial antebrachial
cutaneous nerve
Triceps brachii muscle
Ulnar nerve
Medial brachial
cutaneous nerve
Intercostobrachial nerve
Serratus anterior muscle
Latissimus dorsi muscle
Thoracodorsal artery and nerve
Long thoracic nerve
Pectoralis minor muscle
Lateral pectoral nerve
Medial pectoral nerve
(75%) principal branch
(25%) principal branch
The nerve supply is from the intercostal nerves (second to seventh); the primary sup-
ply to the nipple is derived from the fourth intercostal nerve.
Cooper’s ligaments
Superficial layer
of deep fascia
Deep layer of
superficial fascia
Rectus abdominis muscle
Pectoralis major muscle
Superficial layer
of superficial fascia
Superficial layer of
deep fascia
Deep layer of
superficial fascia
Serratus anterior muscle
Pectoralis major muscle
Superficial layer of
superficial fascia
The breast is suspended from the pectoralis major muscle fascia and to some extent
by the suspensory ligaments of Cooper. These have to be divided during subglandu-
lar augmentation. The inframammary crease is a discrete anatomic structure that
may be very tightly developed in some women with hypomastia, particularly those
with constricted breasts. Releasing or lowering this anatomic landmark may require
radial scoring of the parenchyma up to the dermis in selected cases. Thin patients

with widely separated breasts often have a significant expanse of poorly padded skin
overlying the intermammary area and sternum; this may provide inadequate cover-
age for an implant and result in significant visibility of the implant.
Preoperative Assessment
Physical Examination
A thorough medical history should be taken, including direct questions about any
family history of breast or ovarian cancer. I have seen several patients with a history
of these cancers who subsequently tested positive for the breast oncogenes when
screened. A thorough physical examination should be performed, paying particular
attention to evaluation of the skin, nails, and joints for signs of collagen vascular
disease and compressive neuropathies.
The surgeon should assess height and weight relationships, particularly the length
and width of the chest and trunk. Skin quality and the thickness of subcutaneous
fat have a significant impact on the choice of implant location—the thinner the pa-
tient, the more likely she is to benefit from submuscular coverage of the implant to
mask rippling.
Breast symmetry should be carefully evaluated, and any preoperative differences
should be documented photographically and pointed out to the patient. Nipple lev-
els should be measured and differences noted. Nipple size and sensation should also
be assessed. The level and tightness of the inframammary fold should be evaluated,
and any plan to drop this fold should be discussed with the patient, because this may
affect the fit of a bra. The size and thickness of the pectoralis major muscles should
be evaluated, because very active, muscular patients often do better with subglan-
dular augmentation than submuscular placement, since the latter may result in rhyth-
mic displacement of the implant during heavy upper body exercise. Finally, and most
important, the breast should be examined for masses. The role of preoperative mam-
mography remains a vexing question. I prefer to have mammograms taken of any
woman over the age of 35 who is contemplating aesthetic breast surgery.
Patient Education
Patient education is vital during consultations, because breast augmentation has one
of the highest incidences of short-term and long-term complications of virtually any
cosmetic operation performed today. All complications should be listed and discussed
individually with the patient, particularly capsular contracture, rippling, deflation,
impact on mammography, and nipple sensation. The potential link with autoimmune
disease should be discussed and placed in proper perspective, and patients should
2241
Chapter 62  Breast Augmentation

also be reassured that breast-feeding will be unaffected by this procedure. Informative
literature should be made available as a routine part of any consultation, and high-
quality photographic documentation is essential. If patients are part of a gel implant
study, all pertinent documentation should be completed meticulously to satisfy study
guidelines. Although breast augmentation often requires subsequent revision surgery
and patients need to be informed of that possibility, most patients remain extremely
satisfied with this procedure and believe they understand its complications and that
its benefits far outweigh the risks.
Preoperative Planning
Determining Breast Volume
The patient’s concept of her ideal breast size strongly influences the ultimate deci-
sion about breast volume. I always inquire what the patient thinks of her present
breast size and ask her to bring in a padded bra or a picture that provides a better
indication of a breast volume that is more to her liking. Photographs that illustrate
women whose breast size approximates the size that she desires can provide a good
indication of the degree of enhancement that the patient is looking for. Digital im-
aging can also facilitate communication when trying to determine the appropriate
breast size. By using an imaging system, the surgeon can demonstrate the various
size increases and the resulting impact these will have on body proportions. When
using such an imaging system, it is important to emphasize to the patient that no
guarantees are implied by the morphed images. This imaging is intended only to give
the patient an idea of possible changes and how they would look, and to help her
to understand the various treatment approaches from which she can choose.
Implant Selection
Implant Fill
Implant selection is influenced in part by the availability of devices. Outside the
United States, cohesive gel–filled form stable implants have become the benchmark
for breast augmentation as well as implant-based reconstruction. Cohesive gel im-
plants have been used in Europe since 1995 and have been available in Canada since
2000 through special approval by Health Canada. One of the advantages of the
newer generation cohesive gel–filled implants is that they feel more natural. Com-
pared with saline-filled breast implants or even conventional gel filled devices, rip-
pling is less common because they are semisolid. Deflation is also not a problem with
2242
Part XI  Breast Surgery

2243
Chapter 62  Breast Augmentation
cohesive gel implants, and if a cohesive gel implant ruptures, it still maintains its
shape and integrity. There are also a number of implant models with varying pro-
jection, height, and width, so there is some flexibility in selecting the best implant
size to balance body proportions and breast aesthetics. A disadvantage of cohesive
gel–filled implants is that they require a slightly larger incision for insertion because
they are semisolid; they are also more expensive. These implants are usually placed
through an inframammary incision.
Surface Texture and Shape
The surgeon must also choose between textured or smooth and round or shaped im-
plants, with low, medium, or high profiles. Textured devices have a somewhat lower
capsular contracture rate than smooth implants, but they have thicker walls and
greater palpability. Texturing may also cause higher rupture rates, but these data are
not conclusive. In general, smooth-walled implants are preferable for use in very
thin–skinned patients to diminish implant palpability. Textured devices are better tol-
erated in thicker-skinned women or those with modest amounts of breast tissue.
Round implants work very well in most women, but some surgeons prefer the ap-
pearance of anatomically shaped implants. When the upper pole of the breast is de-
ficient, anatomic implants may be particularly helpful, because they can create the
impression of a gentler taper onto the chest wall than a round implant might achieve.
A high profile implant has greater anterior projection with a smaller base diameter
than an equivalent moderate profile implant. High profile implants are best used in
women who want significant anterior projection, as well as in narrow-chested women
in whom the use of a larger-diameter device may cause unsightly underarm bulging.
Note the difference in projection between high profile (left) and moderate profile
(right) implants.

Size
In general, it is wise to use implants with volumes of less than 400 cc for breast aug-
mentation; larger volumes tend to be associated with higher complication rates, in-
cluding complications such as gravitational ptosis.
2244
Part XI  Breast Surgery
This 32-year-old woman was referred to me for a second opinion after she had had
450 cc saline-filled implants inserted through an inframammary approach. Overdis-
section inferiorly and medially, combined with the use of large implants in an effort
to produce cleavage, produced a catastrophic result, with imminent erosion infero-
medially, derotation of the nipples, and incipient synmastia. The ultimate clinical
outcome of this case is unknown.
In recent years there has been a trend toward evaluating implant size based on im-
plant and breast diameter rather than total reliance on implant volume. Although it
is true that implant projection increases with volume, it is also notable that implant
base diameter increases with volume. Added to this is the fact that a moderate pro-
file implant has a much broader base diameter than an equivalent-volume high pro-
file implant. A narrow-chested woman may benefit more from a high profile implant
with a narrower base diameter so as to minimize the risk of the implant bulging into
the axilla than she would if a broad-based moderate profile implant were inserted.
Volume requirements are also influenced by the patient’s weight: volume requirements
become more extreme and the results less satisfying for overweight patients. Although
a 220 cc implant will provide good contour improvement for a thin patient, this
same implant will not provide adequate contour enhancement for an obese patient.

Measurement of the breast dimensions with calipers provides a reasonable estimate
of the implant base diameter required to achieve an appropriate augmentation and
can serve as a guide as to whether a patient would be a good candidate for a mod-
erate or high profile implant. Breast diameter as well as medial and lateral breast tis-
sue pinch thickness can be used to determine implant volume.
If the base breast diameter in centimeters is X, the medial pinch thickness is Y, and the
lateral pinch thickness is Z, then X  (Y  Z)  the base diameter of the average-
sized implant that will fit comfortably beneath the skin envelope. Part of this decision-
making process depends on the patient’s preference about perceived projection of
the final breast shape. Implant companies provide surgeons with detailed tables of
implant dimensions including the length, width, and height of any given implant vol-
ume; moderate and high profile dimensions and anatomic shape also factor into these
tables. (See the Appendix on pp. 2271 through 2277.)
Adjustable Implants and Temporary Sizers
Adjustable implants first appeared on the market in the form of the Becker expander-
implant, a double-lumen, gel-saline expander with a pull-out fill tube mechanism.
The device is used for breast reconstruction and is designed for permanent place-
ment once expansion to the required volume has been achieved.
The Siltex Spectrum implant is an extension of this principle as applied to breast
augmentation. It is a textured saline-filled implant with a pull-out filler mechanism
that allows for postoperative volume adjustment once implanted. The device is use-
ful in patients who have breast asymmetry or those who are unclear about what size
they would like to achieve. The devices have a leeway of only about 50 to 60 cc once
filled, so major changes in volume are not possible.
Adjustable implants carry the risk of deflating when the fill tube is removed, because
the valve seal can fail, either early or late. Also, valve removal mandates a second
minor procedure in the office, and additional scarring may develop at the site of
removal.
Temporary intraoperative saline sizers provide an alternative to adjustable implants.
Sizers allow a high degree of intraoperative accuracy in volume assessment, partic-
ularly in patients with asymmetrically sized breasts. (See the Appendix on pp. 2271
through 2277.)
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Chapter 62  Breast Augmentation

Incision placement is largely dependent on surgeon and patient preferences. There
are three basic choices: inframammary, axillary, and periareolar. The transumbilical
approach is also used but is less popular than the others. If a patient has a well-
defined inframammary crease with mild ptosis, an inframammary incision is easily
camouflaged postoperatively. However, if the crease is almost nonexistent, as is the
case for patients with severe hypomastia, an axillary placement is preferable. Peri-
areolar incisions are useful in patients with normal to large areolae, but many pa-
tients with marked hypomastia have small areolar diameters that do not lend them-
selves readily to this approach. If a woman has major concerns about nipple
sensitivity, it is probably unwise to employ a periareolar approach.
When using the inframammary approach, I prefer to place the incision approximately
1 to 1.5 cm below the existing crease; this allows the scar to glide up into the new
breast crease, since the augmentation recruits inframammary skin up onto the breast
mound. Failure to perform this simple maneuver results in the scar’s creeping up onto
the lower breast mound and becoming more visible. Incision lengths should be kept
to a minimum, preferably less than 5 cm.
Endoscopic incision
Standard incision
Incision Placement
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Part XI  Breast Surgery

2247
Chapter 62  Breast Augmentation
Subglandular augmentation
Submusculofascial augmentation
Biplanar augmentation
Implant Position
The optimal implant position must also be determined. There are three options: sub-
glandular placement, submuscular placement, or biplanar placement, which is par-
tially submuscular and partially subglandular in its lower pole. Advocates of the sub-
glandular approach believe that it produces a better breast shape. Those who prefer
the submuscular approach believe that the layer of muscle over the implant has a
cushioning effect, thereby promoting a softer breast with less potential for capsular
contracture. The biplanar approach combines the benefits of both approaches.
This 28-year-old woman was referred to me for correction of high-riding implants
caused by incomplete inferior dissection, as discussed earlier. A transaxillary endo-
scopic inferior capsulotomy was done, with her implants left in situ during the pro-
cedure. Note the lowering of the inframammary crease bilaterally.

2248
Part XI  Breast Surgery
Incorrect scar placement
in relation to inframammary fold
Correct scar placement
1 cm below inframammary fold
Patient Position
The patient is placed supine on the operating table with her arms stretched out. The
arms should be well padded and wrapped onto the arm supports with wool padding
to allow the patient to be flexed to an angle of 80 to 90 degrees with safety. This al-
lows accurate intraoperative assessment of implant position in the erect posture;
however, it does place the pectoral muscles under tension. The table should be able
to break at the waist and flex to an angle of 90 degrees. If a transaxillary endoscopic
augmentation is planned, draping should allow access for the surgeon above the
arms during the endoscopic portion of the procedure.
Markings
The inframammary crease is marked, as is the upper pole of the breast. The midline
is marked at the intermammary space. If the inframammary fold is to be adjusted
inferiorly, the degree of lowering should be clearly marked and the patient made
aware of the new location. The location of the incision and its length are then marked.
If an inframammary approach is planned, the incision should be placed 1 cm below
the natural crease because recruitment of abdominal skin up onto the new breast
mound will inevitably pull the scar into the new crease. Failure to carry out this ma-
neuver results in scar migration into a visible position on the breast mound.
Periareolar incisions should be placed at the juncture of the areola and breast skin,
not within the areola itself; any tendency to whitening of the scars will make a scar
within the areola very visible.
Transaxillary markings should be placed high within the axillary floor; the surgeon
should be careful to keep the anteriormost limit of the scar away from the anterior
axillary fold, where it may be visible in sleeveless clothing. In patients with breast
asymmetry, the incisions are placed to reflect the final breast shape and position of the
1 cm

2249
Chapter 62  Breast Augmentation
inframammary fold. If a patient has a higher crease on one side than the other, the
higher crease should be lowered to match the normal opposite crease, and the scar
placement should be positioned lower to reflect the new crease position.
Treatment Algorithms: Choosing the Best Augmentation
Approach
At present, I perform the bulk of breast augmentation procedures through an infra-
mammary incision into the biplanar subpectoral plane in an effort to reduce capsu-
lar contracture. This comes at the expense of less projection per cubic centimeter of
implant volume and a slightly less pleasing shape. There is no doubt that subglan-
dular augmentation provides better shape and projection overall. Subglandular aug-
mentation is best performed in active or muscular individuals with reasonable sub-
cutaneous padding and a moderate-sized breast to start with. This provides the best
implant camouflage and reduces the incidence of visible implant ripples and wrin-
kles. Very small–breasted women with little or no fold definition are well suited to
transaxillary augmentation, as are patients with a propensity for keloid formation,
such as women of Asian or African heritage.
Severe with poor
inframammary fold
APPROACH OPTIONS FOR PATIENTS WITH HYPOMASTIA
HYPOMASTIA
Transaxillary
augmentation
Moderate
Inframammary
augmentation
Well-padded breast
or
Very active, muscular patient
or
Mild ptosis
Subpectoral
Subglandular
Subpectoral
Subglandular
Periareolar
augmentation
Inframammary
subglandular augmentation
Periareolar
subglandular augmentation
Endoscopic
Subpectoral
Options for Patients With Asymmetrical Breasts
Patients with asymmetrical breasts present unique challenges because of the poten-
tial for residual postoperative asymmetry. Breast shape may be complicated by as-
sociated ptosis as well as constricted breast deformity. Selection of asymmetrical im-
plant sizes will correct the problem, and the use of saline-filled implants can be really
helpful, because they allow some degree of intraoperative adjustment to correct sub-
tle residual differences in breast size. In more complex or severe cases, mastopexy
may be necessary, at least on the more ptotic side, a problem that requires patient

2250
Part XI  Breast Surgery
acceptance of more extensive, asymmetrical scar placement. In patients with con-
stricted or tubular breast deformity, extensive release of the lower pole of the affected
breast may be necessary, and in more severe cases, initial tissue expansion may be
the only recourse available to the surgeon. The surgery of constricted or tubular
breasts is not the topic of this chapter, but a basic algorithm for the patient with
asymmetrical breasts is useful.
Normal, asymmetrical breasts
APPROACH OPTIONS FOR MANAGEMENT OF BREAST ASYMMETRY
BREAST
ASYMMETRY
Severe asymmetry
Inframammary
augmentation
Constricted breast
Subpectoral
Subglandular
Subpectoral
Subglandular
Periareolar
augmentation
Inframammary or periareolar
augmentation with release
of lower pole on smaller side
Extensive lower pole release
 expansion
Incision at location of
new inframammary fold
Inframammary
fold
With the patient in the supine position, an inframammary incision is made through
skin and subcutaneous fat. Dissection is carried down to the pectoral fascia, retracting
the breast in a cephalad direction. The lateral border of the pectoralis major muscle
is grasped with an Allis clamp and after the muscle edge is elevated, the subpectoral
plane is entered with blunt scissors dissection.
Operative Technique
Inframammary Approach

2251
Chapter 62  Breast Augmentation
Once entered, the subpectoral plane can be bluntly dissected with either gentle fin-
ger dissection or a metal sound or breast dissector. At this point dissection is entirely
blunt, with no attempt at muscle avulsion. The cavity thus created is now visualized
by inserting a fiberoptic illuminated retractor with suction incorporated.
New inframammary incision closed
Under direct vision, the medial pectoralis major fibers are divided with cautery from
the 3 to 6 o’clock position on the right and the 6 to 9 o’clock position on the left.
Muscle division may be carried through the muscle belly until the grayish-white color
of the prepectoral fascia is visualized or until fat is just visible. Some authors rec-
ommend leaving the muscle intact to prevent visible implant ripples and wrinkles in
the cleavage area. Overdissection medially may result in synmastia with time, a prob-
lem that is extremely difficult to correct.

2252
Part XI  Breast Surgery
Overdissection in an inferomedial direction may result in an unattractive, boxy ap-
pearance to the medial breast, as seen in this woman, who required correction by
open capsulorrhaphy, with nonabsorbable sutures tacking the dermis to the under-
lying rib periosteum. The pocket size and location should be created to place the im-
plant exactly where it is wanted.
Care should be taken when releasing the inframammary crease to prevent abnormally
low implant descent with pseudoptosis and derotation of the nipple areola complex.
Laterally the implant pocket is opened with blunt finger or breast dissector stripping.
The loose areolar tissue in this area offers little resistance, although occasionally
muscle fibers from the lateral border of the pectoralis major may need division. Care
should be taken to avoid overdissecting this area inferolaterally, because it can cause
a lateral implant bulge that is extremely difficult to correct. Superior dissection should
be kept to a minimum to limit the risk of development of excessive upper pole full-
ness. Once the pocket has been prepared, it is irrigated with either saline solution or
an antibiotic solution containing gentamycin, bacitracin, and a cephalosporin. There
is some evidence that this may reduce capsular contracture by limiting skin com-
mensal bacterial contamination. Iodine-containing solutions such as Betadine should

2253
Chapter 62  Breast Augmentation
not be used to wash the pocket, because they have been implicated in silicone im-
plant wall compromise.
Symmetry of the dissected pockets is essential and should be carefully checked. With
symmetrical pockets in place, temporary sizers may be used to evaluate the effect of
different implant volumes on the final shape of the breast.
New inframammary incision closed
After further pocket irrigation, the definitive implants are selected and inserted. Be-
fore insertion, it is useful to apply an occlusive dressing such as Tegaderm or Ioban
over the breast to prevent any contact of the implant with the skin. The surgeon’s
gloves should be changed at this juncture to further minimize implant contamination
with bacteria. The use of a Keller funnel is another useful but currently expensive
technique that can reduce bacterial contamination of the device during insertion.
Implant position is carefully adjusted, particularly if textured surface devices are used.
Closure is performed in three layers with a running subcuticular suture, starting with
a deep fat and fascial layer, followed by a subcutaneous layer. Steri-Strips and an ad-
hesive transparent dressing such as Tegaderm or Op-Site are then applied, followed
by a soft, supportive bra.

2254
Part XI  Breast Surgery
Results
This nulliparous 28-year-old woman requested breast augmentation and liposuc-
tion of her suprapubic area. She had small B cup breasts and well-formed infra-
mammary folds, with modest suprapubic lipodystrophy. Inframammary subpectoral
augmentation was performed with 275 cc smooth, round, saline-filled, high profile
implants; liposuction was also done in the suprapubic area. She is shown 9 months
postoperatively.

2255
Chapter 62  Breast Augmentation
Inframammary augmentation was performed in this 27-year-old woman with a long,
narrow chest and small B cup breasts. Her breasts were augmented with 325 cc
smooth, round, saline-filled implants inserted in a subpectoral position. She is shown
preoperatively and 12 months postoperatively.
Subglandular Approach
If a subglandular placement is planned, dissection is carried down to the pectoralis
major fascia, and the breast gland is simply dissected off the muscle until an ade-
quately sized pocket has been fashioned. Care should be taken medially, where in-
ternal mammary perforators may penetrate the breast from within the substance of
the muscle; these should be meticulously cauterized. Care should also be exercised
to not dissect too close to the skin to reduce the potential for visible wrinkling, pal-
pability, and erosion. Implant placement, sizing, and closure remain the same as for
partial subpectoral placement. Subglandular positioning will tend to provide more
anterior projection of a given implant volume than would be the case with a partial
subpectoral position.

2256
Part XI  Breast Surgery
Results
This 38-year-old woman with grade 2 ptosis requested a breast augmentation and
lift without mastopexy scars; inframammary subglandular augmentation with 325 cc
smooth, round, gel-filled implants was performed. She was willing to accept less-
dramatic nipple elevation if she could avoid the scarring associated with a mastopexy.
The lift produced by subglandular implant placement could not have been achieved
with submuscular augmentation. Although this did not produce an ideal mastopexy
effect, the patient was satisfied with the outcome, which achieved her goals.
This 32-year-old aerobics instructor specifically requested subglandular placement
to minimize implant displacement during exercise. She is shown after inframammary
subglandular augmentation with 300 cc smooth, round, saline-filled implants.

2257
Chapter 62  Breast Augmentation
Periareolar Approach
The periareolar approach requires an adequate areolar diameter through which to
operate. The incision should be made directly at the areola-cutaneous junction to
best camouflage the scar. Attempts at placing the scar within the areola may result
in the scar being visible if it turns white on maturation.
Route of
dissection
Route of
dissection
Periareolar access to the subpectoral plane through either subcutaneous or transglandular dissection
Dissection is begun subcutaneously over the breast and proceeds down to the infra-
mammary fold. This is then lifted to expose the underlying pectoralis major muscle,
which can then be elevated for a partial submuscular placement. Alternatively, a sub-
glandular dissection is easily performed through this incision. Another technique
used by some surgeons is to bisect the breast below the areola and approach the im-
plant pocket directly through the substance of the breast. Either approach works sat-
isfactorily, but patients should be warned of the potential for some sensory loss in
the nipple-areola complex, usually temporary in nature.

2258
Part XI  Breast Surgery
Results
Periareolar subglandular augmentation with 325 cc smooth, round, saline-filled im-
plants was performed in this 26-year-old woman with small C cup breasts. The pa-
tient had a pleasing result, with restoration of upper pole fill and enhanced cleavage.
Transaxillary Approach
The original transaxillary approach was an essentially blind operation that made
medial visualization difficult for securing hemostasis or accurately dividing muscle
fibers. The use of the endoscope has substantially improved the accuracy and pre-
dictability of this operation. Crease symmetry, muscle division, and implant posi-
tioning can be achieved with a greater degree of confidence and ease.
Equipment Required for Endoscopic Transaxillary Augmentation
 10 mm 45-degree down-viewing breast endoscope
 Three-chip endoscopic camera with compatible O ring connector
 Emory breast retractor handle (right-angled handle) with incorporated suction port
 Fiberoptic cable with compatible connection to the endoscope
 Suction tubing
 Emory insulated cautery dissector and handle (right- and left-handed variants)
 Electrosurgical unit with appropriate connecting cable to the cautery dissector handle
 Blunt dissector (several designs available)
 Fog-reduction agent
 Long vertical container for warm saline solution to heat the endoscope lens for fog re-
duction
 Mobile wheeled endoscopic cart containing camera-video output and monitor with
video recorder
The patient is placed supine on the operating table with adequate access above the
arms for the operating surgeon.

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Chapter 62  Breast Augmentation
Before surgery, if lowering of the crease is planned, the surgeon should mark the
original inframammary crease as well as its new, lower location. The axillary inci-
sion is made in the midaxillary floor behind the anterior axillary fold to camouflage
the scar adequately. The fat of the axillary floor is dissected with a blunt scissors-
spreading action to prevent damage to the intercostobrachial nerve. The lateral pec-
toral fascia is opened by perforating it bluntly with closed scissors; with the use of
a spreading action, the subpectoral plane is entered. This is facilitated by grasping
the lateral pectoral muscle border between the thumb and index finger of the left
hand while dissecting beneath it with scissors. Once the subpectoral plane has been
breached, it can be bluntly opened up with an Emory dissector, Hegar dilator, or
similar instrument. No attempt is made at this point to divide muscle fibers. The en-
doscope sheath is then inserted into the pocket while the endoscope itself is placed in
warm saline solution or water to prevent lens fogging.
Transaxillary breast augmentation is illustrated, with endoscope insertion into the
subpectoral plane. The planned muscle division is marked inferomedially. Once the re-
tractor is in place, the warmed endoscope is inserted through the sheath. The orien-
tation of the camera is carefully checked to ensure that the anatomy is correctly vi-
sualized. The toe of the retractor is pulled upward to expose the work face of the deep

2260
Part XI  Breast Surgery
surface of the pectoralis major muscle medially. Suction is connected, because smoke
evacuation is vital to this part of the operation. Using a tested, insulated, spatula-
tipped cautery, the medial muscle fibers are divided until the prepectoral fascia is seen;
this marks the endpoint of dissection. The extent of muscle release is identical to that
described for the inframammary approach. The pocket should be inspected carefully
to ensure that division of the inferolateral muscle fibers is adequate.
Pocket dissected
The released pectoral muscle and pocket are bluntly dissected inferolaterally before
the implant is inserted. Adequate inferior dissection is essential to correct implant
position; failure to perform this maneuver may result in high-riding implants. The
inferior dissection should match the external markings placed on the breast mound
preoperatively if the surgeon plans to lower the breast crease. After the pocket is ir-
rigated, the implants are inserted.
The implants are removed from their containers, fill tube valves are placed on the
ends of the tubing, and a small volume of saline solution is instilled to remove any
extra air. The deflated implant is then prepared for insertion by shaping it into a dou-
ble row that is narrowed at the end for easier insertion.

Implant rolled and inserted
nserted
2261
Chapter 62  Breast Augmentation
The implant is inserted into the prepared submuscular pocket and inflated. Note its
biplanar position.
The patient should be evaluated in the sitting position to establish conclusively that
symmetry has been achieved and that the implants are not positioned too high. The
axilla is closed in a two-layer fashion; no drains are placed. An transparent occlu-
sive dressing is applied.

2262
Part XI  Breast Surgery
Results
This 26-year-old woman with very mild breast asymmetry requested breast aug-
mentation with the least noticeable scar. Her right breast was slightly larger and
more ptotic than the left. She had transaxillary augmentation with placement of 375 cc
smooth, saline-filled implants inflated to 400 cc on the left and 375 cc on the right.
She is shown 6 months after surgery; asymmetrical transaxillary augmentation im-
proved her symmetry and achieved her goals of not having visible scars on the breast
mound. A transaxillary scar is seen in the left axilla.

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Chapter 62  Breast Augmentation
Air
Transumbilical breast augmentation (the
TUBA procedure) is performed through
a superior periumbilical incision. Blunt
dissection into the inferomedial aspect
of the breast is performed, and a sig-
moidoscope-like sheath is passed into
the tunnel. A blunt dissector may be in-
serted into either the subglandular or
subpectoral plane.
This young woman requested transaxillary augmentation. She is shown before and
1 year after augmentation with smooth, saline-filled moderate profile implants. The
patient had an excellent cosmetic result with an enhanced, natural-appearing cleav-
age, fullness of the lower poles, and restoration of upper pole fullness.
Transumbilical Breast Augmentation

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Part XI  Breast Surgery
Postoperative Care
Analgesia can be achieved with opiates, or the use of antiinflammatory agents such
as nonsteroidal drugs and COX-2 inhibitors. Preloading with an oral dose on the day
before surgery seems to help in achieving adequate pain control, and these drugs do
not appear to worsen the incidence of hematomas. Instillation of 10 ml of plain 0.25%
bupivacaine into the implant pocket before closure also provides early postoperative
pain relief, as does the use of bupivacaine infusion pumps such as the OnQ or Stryker
devices.
A soft bra without underwiring is used. Patients should not drive for at least 2 weeks
postoperatively, and high-impact aerobic exercise is discouraged for 6 weeks. Im-
plant massage may be helpful and certainly does not seem to cause harm; it can be
started as soon as the patient is comfortable enough to massage the breasts. The use
of leukotriene inhibitors such as zafirlukast (Accolate) is of debatable benefit but
carries few side effects. Postoperative antibiotics are still used by most surgeons, al-
though there are no hard data that their use is of any more value than that of peri-
operative antibiotics alone in limiting postoperative wound infections.
A balloon tissue expander is inserted and
then inflated with saline solution to cre-
ate the implant pocket. It is difficult to
adjust the pocket with this procedure,
and asymmetry or high-riding implants
are potential complications. Once the
pockets are dissected, the expanders are
removed and the implants are inserted
and inflated to volume before the fill
tubes are removed.

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Chapter 62  Breast Augmentation
Outcomes
The results of breast augmentation are gratifying and provide patients with an im-
mediate enhancement in breast size. The impact of this shape and volume change on
the patient’s psyche has been positively documented. Careful patient selection results
in a highly satisfied patient population on the whole. Clinical outcomes in breast
augmentation are highly satisfactory, with the exception of the occurrence of cap-
sular contracture and implant leakage, both of which will be discussed later in this
section. Early complications of primary breast augmentation, such as hematoma and
infection, are exceptionally rare. Hematoma rates are reported at less than 4% in
most series, and careful attention to intraoperative hemostasis should lower this to
1%. Infection is also extremely rare, and the use of perioperative antibiotics, antibi-
otic lavage of the implant pocket, and meticulous attention to technique with the in-
corporation of a no-touch technique have substantially reduced infection rates. Al-
though implant and expander infection rates have ranged from 3% to 35% in
reconstructive breast surgery, cosmetic augmentation mammaplasty infection rates
should be less than 1% in experienced hands. The importance of meticulous oper-
ative technique has been emphasized repeatedly, not only for implant infection re-
duction but what is more important, for reducing capsular contracture, which is
thought to be related to subclinical infection.
Capsular contracture undoubtedly remains the most frustrating and most common
complication of breast augmentation. Numerous investigators have reported their
experience with saline, gel, and smooth and textured devices, with markedly differ-
ing results. The Mentor and Allergan studies have helped clarify some of the data.
Mentor reported an 8.3% risk in primary augmentation and a 16.3% risk in sec-
ondary augmentation. Allergan reported a 15% to 20% risk in both augmentation
and reconstruction patients together. These figures remain high. From the plethora
of retrospective and some prospective data available, several conclusions seem valid.
Saline-filled implants are clearly associated with a reduction in capsular contracture
rates in most reported studies. Polyurethane coating of gel-filled devices reduces cap-
sular contracture to less than 1% during the first 10 years after surgery. In an effort
to mimic the polyurethane surface by texturing of the gel implant wall, some reduc-
tion of capsular contracture occurs. Alternative fillers have been disappointing both
in their rupture rates and their capsular contracture rates; hydrogel implants
(polyvinylpyrrolidone [MISTI Gold]) and lipid-filled devices (Trilucent) failed to live
up to expectations and were withdrawn from the market. Double-lumen saline-gel
combination implants have had a good performance record, and texturing appears
to further reduce their contracture rates. Although U.S. surgeons have limited access
to cohesive gel implants, plastic surgeons elsewhere have had considerable experi-
ence and report positive results with the newer form-stable cohesive gel devices; how-
ever, accurate long-term follow-up data are still sparse. Capsular contracture is pur-
portedly low, but patients often complain of breast stiffness because of the firmness

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Part XI  Breast Surgery
of the gel. The new generation of softer cohesive gels appears to have solved this
problem. Implant position is still a significant factor in reducing capsular contrac-
ture. Partial submuscular placement does appear to reduce contracture rates, possi-
bly because of the massaging effect of the pectoral muscles. A 58% incidence of cap-
sular contracture has been noted when smooth silicone devices were placed in the
subglandular position, compared with a 9% rate when implants were placed in the
subpectoral plane; similar results were found with smooth saline implants.
To prevent capsule formation, steroids have been instilled intraoperatively into saline
implants, with variable success. A reduction in capsular contracture has been re-
ported with the use of 40 mg of methylprednisolone within a double-lumen pros-
thesis, whereas a higher incidence of erosion, skin atrophy, and ptosis has been
demonstrated, despite a drop in capsular contracture rates, when steroids were in-
stilled within the implant. This is not surprising, given that steroids are heavier than
water and gravitate to the lower pole of the implant, thereby enabling diffusion to
occur to the lower pole of the breast. Intraluminal steroid injection should not be
performed, because steroids tend to settle inferiorly, and diffusion into the tissues
can cause thinning of the lower pole of the breast, increasing the potential for ex-
trusion. Systemic antibiotic prophylaxis, per se, has not been shown to affect con-
tracture rates, but it has been shown that topical pocket lavage with a mixture of
cephalosporin and gentamycin may positively affect contracture rates. Use of Mladick’s
no-touch technique also appears beneficial. Some consider postoperative breast com-
pression helpful, and it carries the benefit of involving the patient in her own care.
The value of oral vitamin E therapy is highly conjectural.
For treating established capsular contracture, the use of saline and textured implants
may be helpful, whereas subglandular implants may be converted to the submuscu-
lar or biplanar location. The question of whether a total capsulectomy is preferable
to an anterior capsulectomy remains unanswered. It has been shown that subglan-
dular capsules should be totally removed, because an anterior capsulectomy alone
tends to result in higher recurrence rates. Implant malposition remains a significant
cause for reoperation at rates of 1.4% to 4.6% in primary augmentation and as high
as 14.8% in secondary augmentation.
Concluding Thoughts
Implant-based breast augmentation is gaining in popularity once more and is an ef-
fective procedure for breast enhancement. There are more implant choices, both in
filler materials and contours. Careful selection of the appropriately shaped device for
a given breast morphology can produce stable, long-lasting results. These results de-
pend on good surgical technique based on clear anatomic principles.

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Chapter 62  Breast Augmentation
Clinical Caveats
 Inframammary incisions should be placed below the inframammary fold, because
they tend to rise up onto the breast mound as skin is recruited from below.
 Overdissection should not be done in any direction; the pocket size and location
should be created to place the implant exactly where it is wanted.
 Overdissection through the pectoralis major muscle medially, as well as dissection
into the subcutaneous fat, may increase the propensity for ripples and wrinkles to
appear, whereas inferomedial overdissection produces a boxy breast deformity.
 The cavity should never be washed with Betadine solution.
 When using endoscopic equipment, the camera orientation should be checked to
prevent inadvertent thoracic penetration.
 To prevent cutaneous burns, endoscopic cautery insulation should be checked be-
fore it is used.
 The no-touch technique is used whenever possible to reduce implant contamination.
 Extremely large implants should be avoided, because implant volumes of more
than 400 cc tend to be associated with higher complication rates.
Annotated Bibliography
Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and reconstruc-
tive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical
study. Plast Reconstr Surg 117:30-36, 2006.
This landmark paper reviews the 6-year prospective data highlighting the value of triple
antibiotic irrigation in reducing capsular contracture after implant surgery. It empha-
sizes the likely role of subclinical bacterial contamination in the generation of capsular
contracture.
Cronin TD, Gerow FJ. Augmentation mammaplasty: a new “natural feel” prosthesis. Trans-
actions of the Third International Congress of Plastic Surgery, Washington, DC, 1963,
pp 41-49.
A historically important paper in which the authors presented their initial experience
with the “new” gel-filled prosthesis, a major breakthrough for breast augmentation as
well as breast reconstruction.

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Part XI  Breast Surgery
Hester TR Jr, Nahai F, Bostwick J III, et al. A 5-year experience with polyurethane-covered
mammary prostheses for treatment of capsular contracture, primary augmentation
mammaplasty, and breast reconstruction. Clin Plast Surg 15:569-585, 1988.
The authors presented the Emory University 5-year experience with these outstanding im-
plants. Polyurethane-coated devices revolutionized the approach to capsular contrac-
ture and paved the way for the current generation of silicone-textured saline- and gel-
filled implants.
Mladick R. “No-touch” submuscular saline breast augmentation technique. Aesthetic Plast
Surg 17:183-192, 1993.
The importance of the no-touch approach in an effort to reduce implant contamination
as a means of reducing capsular contracture is emphasized. The author’s minimal inci-
dence of this complication suggests that more attention should be paid to this technique.
Price CI, Eaves FF III, Nahai F, et al. Endoscopic transaxillary subpectoral breast augmen-
tation. Plast Reconstr Surg 94:612-619, 1994.
The first description of endoscopic breast augmentation; the technique used the transax-
illary approach and helped to resurrect this approach for routine augmentation. This
article led to further advances in endoscopic augmentation and attempts at endoscopic
capsulotomy and made developments in endoscopic lumpectomy and latissimus breast
reconstruction possible.
Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in
a wide range of breast types. Plast Reconstr Surg 107:1255-1272, 2001.
The author brings his vast experience to the concept of dual-plane augmentation, em-
phasizing the important relationship of implant position to that of the overlying breast
in an effort to improve the final shape of the augmented breast.
Suggested Readings
Baker J. The effectiveness of alpha-tocopherol (vitamin E) in reducing the incidence of spher-
ical contracture around breast implants. Plast Reconstr Surg 68:696-698, 1981.
Berthe JV, Van Geertruyden JP. Osmotic instability of hydrogel-filled breast implants. Br J
Plast Surg 54:465-466, 2001.
Cairns TS. Capsular contracture after breast augmentation: a comparison between gel- and
saline-filled prostheses. S Afr Med J 57:951-953, 1980.
Camirand A, Doucet J, Harris J. Breast augmentation: compression—a very important fac-
tor in preventing capsular contracture. Plast Reconstr Surg 104:529-538; discussion 539-
541, 1999.
Cash TF, Duel LA, Perkins LL. Women’s psychosocial outcomes of breast augmentation with
silicone gel-filled implants: a 2-year prospective study. Plast Reconstr Surg 109:2122-
2123, 2002.
Chatrath P, Oliver DW, Walker MS, et al. Anti-soya antibodies and Trilucent breast implants.
Plast Reconstr Surg 111:98-102, 2003.