Phẫu Thuật Tạo Hình (Tập 5): Tuyến Vú – Neligan (2018)

16
SECTION I
CHAPTER 2 • Preoperative evaluation and consultation for breast augmentation
many critical surgeons began developing more system-
atic approaches to the breast augmentation process,4–6
the goals of which include the critical analysis of objec-
tive measurements to better predict the outcome of each
patient’s surgical experience, and to minimize operative
risk of this elective procedure. Surgeons today need to
understand these varied approaches and consider how
they apply to their personal technical and aesthetic
principles. As always, there can be no one correct tech-
nique, but each analysis system contributes significant
critical detail to the breast surgeon’s ability to provide
reproducibly beautiful, safe results. Important aspects
of several of these will be discussed.
Finally, FDA approval of shaped and highly cohesive
breast implants in the United States in 2012 and 2013
ushered in an era of additional options in both recon-
structive and aesthetic breast surgery.7 Today the breast
augmentation patient has more options, increased
safety, and better potential outcomes as a result of this
significant advance in implant technology8–10 (Fig. 2.2).
Consultation process
Today’s electronic medical record (EMR) affords the
physician the opportunity to have a very complete
medical history before the patient enters the office (Fig.
2.3). The electronic documents can be customized to
gather a complete breast and family history. Preopera-
tive mammography should be obtained for patients
over age 35 as per standard guidelines or at any age in
patients with significant risk factors. While beyond the
scope of most consultations, plastic surgeons should
have a basic understanding of modern genetic testing
for the breast cancer genes as this is a common question
raised during the consultation.
Patients have most often spent a great deal of time on
Internet research, and this is rarely accurate or produc-
tive. It is the author’s strong recommendation to focus
on your own information process and steer away from
a long discussion on “what ifs” from less reliable sources.
A key component of the initial consultation is to ascer-
tain that the patient has realistic expectations for the
procedure.
The next portion of the discussion should focus on
the patient’s goals. This should include not only her
desired size but also the shape of her desired breast.
Should it be natural or augmented in its appearance?
There is certainly no consensus, but a recent paper
clearly shows a majority preference toward a slightly
fuller lower pole of the breast, a straight upper pole with
Fig. 2.1  Round implants showing different profile shapes (low profile to ultra high
profile).
Low profile
Moderate profile
High profile
Ultra high profile
Fig. 2.2  Shaped implants. (A) Mentor Memory Shape. (B) Allergan 410 (low to
full height). (C) Sientra HSC 2 Shaped (low height, round base, shaped classic).
A
Low height
Moderate height
Full height
B
Low height
Round base
Shaped classic
C

17
Historical perspective
Fig. 2.3  Example of EMR that can be customized to practice preferences.
HPI
Breast/nipple
PREOPERATIVE INFORMATION
Small breasts
Breast ptosis
Weight loss changes
Uneven breasts; nipple/areola issues
Problems with prior breast surgery
Capsular contracture
Implant rupture
32
34
36
38
40
42
44
A
B
BB
C
CC
D
DD
> than DD
Chief Complaint & Symptomology for Breast/Nipple
Nipple
Inframammary
Axilla
Mastopexy
Umbilicus
Previous Breast Incision
Subglandular
Submuscular
Previous Implant Position
HPI Breast/Nipple (aug/mastopexy) Notes
1 month ago
2 months ago
3 months ago
4 months ago
5 months ago
6 months ago
7 months ago
8 months ago
9 months ago
10 months ago
11 months ago
1 year ago
2 years ago
3 years ago
4 years ago
5+ years ago
never
Last Mammogram -
no children
1 child
2 children
3 children
4 children
5 children
6 children
Children - # of -
Mentor
Allergen
Other
Previous Implant
Previous Implant Size – Right
mother
father
spouse
brother
sister
cousin
friend
self
aunt
daughter
fiance
Patient Accompanied By -
Patient's Current Size -
32
34
36
38
40
42
44
A
B
BB
C
CC
D
DD
> than DD
Patient's Desired Size -
150
800
Previous Implant Size – Left
150
800

18
SECTION I
CHAPTER 2 • Preoperative evaluation and consultation for breast augmentation
no consensus as to what size implant in relation to the
patient’s starting base diameter is best. The author’s
preference is to select an implant that is always within
1 cm of the patient’s natural base diameter. This allows
for enough width to give the breast an adequate shape,
but not so much that medial or lateral stretch would
cause tissue damage.
For some surgeons there is truly no flexibility to
exceed this measurement, and this has led to a nearly
dictatorial practice of breast augmentation. They
propose that violating the patient’s intrinsic base diam-
eter leads to inevitable and irreversible tissue damage
with subsequent complications including implant
visibility, rippling, loss of nipple sensation, and early
implant malposition and ptosis. All of these lead to a
significantly higher complication and re-operation
rates.3 This author agrees in principle, but as always,
there are significant exceptions including the constricted
breast, tubular deformity, and severe hypoplasia that
require a more aggressive and individualized approach
through the consultative and surgical process.
Measurement of the breast envelope
Anterior–posterior skin stretch, nipple to fold stretch,
medial and lateral skin pinch, and other similar mea-
surements are unique attempts to categorize the quality,
the volume, and elasticity of each patient’s breast enve-
lope. Each surgeon needs to decide which technique
a slight up-turn to the nipple at the most projecting
portion11 (Fig. 2.4).
Patient examination
Complete physical examination should include each
patient’s height, weight, and current bra size. Clear
documentation of any chest wall and spinal deformities
are essential. Documentation of asymmetry of breast
size, shape, nipple position, inframammary fold (IMF)
position, shoulder position, and axillary breast tissue
fullness and quality are all key components. A thorough
breast examination to exclude any masses or adenopa-
thy should be completed. The quality of the breast tissue
and skin should be noted (Fig. 2.5).
Multiple evaluation systems exist to guide the surgeon
in the preoperative process. Key components of all
include base diameter, sternal notch to nipple distance,
nipple to IMF distance, intermammary distance, and
upper pole skin pinch. This should be recorded accu-
rately in the patient’s chart (Fig. 2.6). Each evaluation
system mentioned previously uses a differing technique
to assess the elasticity and quantity of the skin envelope.
This should be clearly assessed on each patient and each
breast. A complete description of each evaluation system
is not possible, but there are several key components
that demand further discussion.
Base diameter
All the modern systems for selecting breast implants
place an essential weight on respecting the patient’s
inherent breast base diameter; that is, the distance from
the medial breast to the anterior axillary line. There is
Fig. 2.5  Important differences in chest wall shape. (A) Flat chest wall: any implant
placed in this patient is likely to remain centralized with effective volume
enhancement. (B) Round chest wall: high profile implants will tend to fall laterally
early. Textured implants may stay in position more effectively. In addition, part of
the volume added effectively flattens the chest and contributes less to final volume.
These patients may need additional implant size to obtain their desired result.
A
B
Fig. 2.4  Ideal breast proportions. Representative three-quarters profile view with
standard breast parameters as used in the survey: upper pole to lower pole ratio,
nipple angulation, and contour of upper and lower poles. The visible breast has an
upper pole to lower pole ratio of 45 : 55, straight upper pole, and convex lower
pole. U, upper pole; L, lower pole; UPL, upper pole line; LPL, lower pole line; NM,
nipple meridian; UPS, upper pole slope; LPC, lower pole convexity. (Reproduced
with permission from Mallucci P, Branford OA. population analysis of the perfect
breast: a morphometric analysis. Plast Reconstr Surg. 2014;134:436–447.)

19
Patient examination
Fig. 2.6  One of several optional forms available for recording patient measurements and surgical planning.

20
SECTION I
CHAPTER 2 • Preoperative evaluation and consultation for breast augmentation
Pinch thickness
The upper pole pinch thickness is an essential compo-
nent in the evaluation process. This will assist in the
proper selection of both implant type and pocket during
the patient analysis. Thickness of other portions of the
breast parenchyma can also be considered when select-
ing an implant size, diameter, and considering when
they will utilize to perform this evaluation, and practice
it diligently. The error of either over- or under-filling the
breast will be quickly recognized, and the young breast
surgeon can avoid these problems through the experi-
ence of senior breast surgeons. The systematic approaches
provide a means to adjust the breast implant volumes
selected to compensate for either a tighter or looser skin
envelope to produce a more satisfactory result (Fig. 2.7).
Fig. 2.7  Differences in skin envelope. (A–C) This patient has a tight skin envelope, minimal breast tissue, and chest wall asymmetry. Sientra shaped classic implants,
submuscular position (right: 400 cc; left: 350 cc). (D–F) This patient has a loose skin envelope and moderate breast tissue. Mentor Moderate plus round smooth silicone
implants in a subglandular position (right: 300 cc; left: 275 cc).
A
B
C
D
E
F

21
Patient examination
Sizers
There is no best way to size breast implants. This again
falls into the category of experience, systematic approach,
and preference. The author’s preference is patient-based
within the limits of each individual’s base diameter.
Patients are allowed to use a commonly available volu-
metric sizing system (Fig. 2.9). This is placed in a tight
sports bra for volume only (not shape). The patient’s
selected size is then imaged on the 3D imaging system
based on her other measurements.
Implant selection
Simplistically, there are three choices in implant selec-
tion: saline vs. silicone, smooth vs. textured, and round
vs. anatomic. Once the combinations of these are con-
sidered including the different heights and projections
and brands available, the combinations are essentially
too numerous to count. Each surgeon must evaluate the
currently available safety data, patient characteristics,
measurements, costs, and their own surgical technique
to select the best implant for each situation.
The author’s preference based on current data is to
use a textured implant in almost all situations. The
decrease in capsular contracture13 and the author’s
perception of implant positional stability are the main
basis for this decision. In addition, the use of shaped
and highly cohesive gel implants dictate the need for
texturing to prevent rotation and implant malposition.
Incision selection
Four incisions have been classically described for breast
augmentation: inframammary, transaxillary, periareolar,
and transumbilical. The risks and benefits of each of
these incisions should be discussed with the patient, and
then the best recommendation should be made based
tissue modification such as mastopexy may be neces-
sary. Briefly, when soft-tissue pinch is less than 2 cm in
the upper pole, the implant will be less visible and
palpable in the submuscular position. In addition, a
shaped cohesive or saline implant fits better in the
submuscular plane in this situation as well.
3D imaging
Once a thorough physical examination has been com-
pleted, the patient can undergo 3D imaging where
measurements can be taken, and subsequent simula-
tions can be performed. An imperative in the 3D process
is that size should not be selected by this technique, only
confirmed. Selecting a breast implant size via imaging
violates all the principles of safe preoperative planning.
The design of the imaging software is to make any size
implant look good despite the patient’s anatomy.
With this as a preface, it has become clear that as a
measurement and predictive tool, 3D imaging is a useful
clinical and marketing tool for the aesthetic breast
surgeon. Multiple studies have confirmed the accuracy
and patient satisfaction of 3D imaging to be as high as
90% (Fig. 2.8).12
Fig. 2.8  Example of measurements and display of modern 3D image.
Fig. 2.9  Volumetric sizers are used for patients to try on sizes. Implants do not fill
bras or T-shirts correctly and give erroneous size estimates.

22
SECTION I
CHAPTER 2 • Preoperative evaluation and consultation for breast augmentation
implants. Studies have shown better ability to perform
mammography, which is important in all patients, but
especially in those with a strong family history of breast
cancer. In patients with thin soft tissue, the implant will
be less visible and palpable. This is especially significant
with both saline and the newer more cohesive silicone
implants.
Negative aspects of submuscular placement include
increased risk of animation deformity in patients with
significant pectoral muscle development and/or larger
implants, increased postoperative pain, and the risk of
long-term “piston deformity” with smooth and espe-
cially saline implants (lateral and inferior malposition).
When the submuscular plane is used, the dual plane
technique14 can be adapted to achieve outcomes similar
to subglandular effects but maintain better upper pole
coverage. This technique allows additional manipula-
tion of lower pole and glandular tissue. It is helpful in
the correction of the more ptotic breast, asymmetry of
the breast envelope, and asymmetry of nipple position
(Fig. 2.10). In using the dual plane, it is essential that the
surgeon maintain medial attachment of pectoral muscle
to avoid window shade deformity medially.
Subglandular
This plane remains an excellent option for breast aug-
mentation with better correction of ptosis and likely
similar risk of capsular contracture with textured
implants. There is clearly a higher risk of capsular
contracture with smooth implants in recent literature.
Subfascial
This dissection plane separates the breast tissue from
implant with a theoretical decrease in capsular contrac-
ture. It also can eliminate the risk of animation deformity
and in theory has ideal properties. This plane is more
common outside the United States and requires a more
difficult dissection plane.
Who decides what’s best –
surgeon or patient?
Author’s personal algorithm15
In the author’s practice, patients are allowed to try on
size, and then all measurements are performed. Implants
are selected with the following algorithm:
1. Base diameter is measured. This should not be
violated by more than 1 cm either smaller or larger
to create an attractive breast. Exceptions are the
tuberous, constricted, or truly absent breast.
on implant selection, surgeon preference and ability,
patient preference, and ideal surgical technique.
Inframammary incision
This incision allows complete visualization of the pocket
in either the submuscular or subglandular plane. It can
be used in either primary or secondary breast surgery.
The incision needs to be planned in the projected fold,
and recommended techniques exist to predict this accu-
rately. The length of the incision will vary with implant
type, longer with the newer cohesive gel implants.
Periareolar incision
Hidden at the junction of the areolar pigment and breast
skin, this incision is best in lightly pigmented patients.
Patients who have a sharp demarcation in their areolar
pigment also tend to have a well-hidden scar compared
with those whose pigment fades into the breast skin.
This incision is helpful when adjusting the inframam-
mary fold, or for scoring the breast tissue in patients with
constricted breast deformity. Recent literature has shown
a higher risk of both infection and capsular contracture
with this incision especially with the use of textured
devices. Additional disadvantages include more difficult
visualization and inability to place silicone or cohesive
implants with small areola diameters (<40 mm).
Transaxillary approach
The transaxillary incision can be used to perform either
saline or silicone augmentation. In the past this has been
used with blunt technique as well, but today this should
all but be condemned as the risk of increased hema-
toma, pocket irregularity, and unnecessary tissue injury
are significant. With the endoscopic technique, this
approach can also be used to place newer more cohesive
implants, although this can require a larger axillary
incision and tunnel. This incision avoids a scar on the
breast but limits the manipulation of the breast tissue
and likely requires a second incision for any revisionary
procedures.
Transumbilical incision
Again there is no incision on the breast mound, but this
incision can only be used with saline implants. Again,
blunt dissection and inability to use for revision also
limit its utility.
Pocket selection
Submuscular
This location has been shown to have a decreased inci-
dence of capsular contracture – at least with smooth

23
Who decides what’s best – surgeon or patient?
their size goal is either too large (a smaller implant
must be used) or too small (a mastopexy must be
performed). There is limited flexibility as patients
are told that while they are the consumer, it is still
my role to be the doctor. The beauty of the newest
implants is their longevity and the fact they
should be much less likely to require revision
surgery due to device failure. Therefore, both the
patient’s and physician’s decisions should also
prevent this.
As a procedure driven by patient demand, many patients
shop for a surgeon who will perform breast augmenta-
tion regardless of size and tissue limitations. This
leads to short-term satisfaction, but long-term patient
complications.
I believe each surgeon needs to decide his or her own
philosophy on breast augmentation: patient choice or
surgeon choice. If you allow the patient to dictate the
2. Sternal notch to nipple distance is measured to
assess breast height:
a. >21 cm – tall height implant
b. 18–21 cm – moderate height implant or round
device
c. <18 cm – oval implant
(This can be adjusted based on the patient’s
axillary fullness, goals for shape, pectoral muscle
development, and chest shape.)
3. Projection is used to fill the skin envelope. This is
assessed by measuring the nipple to
inframammary fold distance with the breast skin
on stretch. High, moderate, or low projection
implants are selected based on the patient’s skin
envelope and size goals as much as possible.
4. Once the base diameter, implant height, and
projection are selected, the volume is
predetermined. Patients must be counseled when
Fig. 2.10  Dual plane technique.
$
%
&
'
(
)

24
SECTION I
CHAPTER 2 • Preoperative evaluation and consultation for breast augmentation
Reasonable breast enhancement with safety and longev-
ity is an admirable goal. High re-operation and compli-
cation rates, unnatural size, and appearance demand a
critical re-evaluation of both the patient’s and surgeon’s
goals in augmentation mammoplasty (Fig. 2.11).
Conclusion
Breast augmentation has evolved from a subjective
surgery with a high incidence of complications, to an
objectively determined cognitive and aesthetic proce-
dure. New implants and better data supporting dimen-
sionally planned, meticulously performed surgery have
allowed the plastic surgeon to improve both safety and
cosmetic outcome. The modern breast surgeon should
strive to master these options and details in pursuit of
the ideal result for each patient.
volume that they can select for their augmentation, then
the surgeon cannot determine at least one or more of the
implant characteristics. In other words, if you measure
all the characteristics of the patient’s tissue, then the
volume of the implant they can accommodate is prede-
termined. If not, then the surgeon is not in control of the
procedure.
As you develop your personal technique for breast
augmentation, you must honestly decide which methods
suit your patient philosophy, risk aversion, and surgical
technique. You must build your consultation, surgical
principles, and practice around this concept. An example
of how two surgeons might treat the same patient helps
to illustrate the point (Table 2.1).
The first surgeon measures all characteristics of the
patient’s breast – diameter, height (for a shaped implant),
tissue envelope (in this case selecting a round, moderate
projecting device) – and therefore, from one company’s
catalog, can only select a 255 cc implant to fit into this
breast properly.
The second surgeon allows the patient to “select” a
400 cc size implant. In trying to keep similar measure-
ments, he must make significant compensation. The
closest implant to match this size request is a high profile
implant, 385 cc with a larger base diameter than the
patient’s actual size. As discussed above, in some
patients over time this will lead to abnormal tissue
stretch, thinning, wrinkling, problems with bottoming
out, implant malposition, and therefore a higher re-
operation rate. Even in the hands of the best surgeons,
these complications are statistically significant.
While some patients will have a successful long-term
result in both of these scenarios, others in the “patient
size selection” model will not. As surgeons and physi-
cians, we must live by the goal of “First do no harm”.
Fig. 2.11  A 24-year-old patient shown before and six months after Sientra round
base silicone submuscular breast augmentation (320 cc). This patient with small
breasts and a tight skin envelope still has a very natural enhancement with a result
similar to the 45%/55% ratio discussed earlier.
A
B
Table 2.1  How two surgeons might treat the same patient
Surgeon A
Surgeon B
Base diameter
11.0 cm
Base diameter
12.3 cm
Height
Moderate
Volume
385
Projection
Moderate
Height
Moderate
Volume
255 cc
Projection
High
(See discussion in text below)

25
Conclusion
3. Tebbetts JB, Teitelbaum S. High- and extra-high-projection breast
implants: potential consequences for patients. Plast Reconstr Surg.
2010;126:2150–2159. Surgeons should carefully review this paper to
understand the potential damage of a poorly selected or oversized implant.
It is essential to understand how patient goals may not produce safe long
term results.
4. Tebbetts JB, Adams WP. Five critical decisions in breast
augmentation using five measurements in 5 minutes: the high five
decision support process. Plast Reconstr Surg. 2005;116:2005–2016.
This classic paper presents a system of analysis and planning for breast
augmentation. Its principles should be clearly understood by all aesthetic
breasts surgeons.
13. Stevens WG, Nahabedian MY, Calobrace MB, et al. Risk factor
analysis for capsular contracture: a 5-year Sientra study analysis
using round, smooth, and textured implants for breast
augmentation. Plast Reconstr Surg. 2013;132:1115–1123. This review of
the largest FDA manufacturer cohort shows clearly the differences in
implant pocket, texturing and incision selections. It should be reviewed as
part of the consultative and decision making process.
14. Tebbetts JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272. The modern breast surgeon needs to
understand the power of the dual plane technique. Its facility to shape the
breast in many situations will improve any surgeons outcomes.
15. Schwartz MR. Algorithm and techniques for using Sientra’s silicone
gel shaped implants in primary and revision breast augmentation.
Plast Reconstr Surg. 2014;134:S18–S27. This is the authors preferred
technique for the evaluation, planning and procedure for breast
augmentation. Text and Video provide a clear demonstration of this
method.
Access the complete reference list online at

25.e1
References
References
1. ASAPS. Current procedural statistics. [Online] Available at >; 2014.
2. Gladfelter J, Murphy D. Breast augmentation motivations and
satisfaction: a prospective study of more than 3,000 silicone
implantations. Plast Surg Nurs. 2008;28:170–174.
3. Tebbetts JB, Teitelbaum S. High- and extra-high-projection breast
implants: potential consequences for patients. Plast Reconstr Surg.
2010;126:2150–2159. Surgeons should carefully review this paper to
understand the potential damage of a poorly selected or oversized implant.
It is essential to understand how patient goals may not produce safe long
term results.
4. Tebbetts JB, Adams WP. Five critical decisions in breast
augmentation using five measurements in 5 minutes: the high five
decision support process. Plast Reconstr Surg. 2005;116:2005–2016.
This classic paper presents a system of analysis and planning for breast
augmentation. Its principles should be clearly understood by all aesthetic
breasts surgeons.
5. Hammond D. Augmentation mammoplasty. In: Hammond D, ed.
Atlas of Aesthetic Breast Surgery. Philadelphia: Elsevier Limited;
2009:51–64.
6. Randquist C, Gribbe O. Highly cohesive textured form stable gel
implants: principles and techniques. In: Hall-Findlay E, Evans G,
eds. Aesthetic and Reconstructive Surgery of the Breast. Philadelphia:
Elsevier Limited; 2010:339–365.
7. Maxwell GP, Gabriel A. The evolution of breast implants. Plast
Reconstr Surg. 2014;134:S12–S17.
8. Stevens WG, Harrington J, Alizadeh K, et al. Five-year follow-up
data from the U.S. clinical trial for Sientra’s U.S. Food and Drug
Administration-approved Silimed® brand round and shaped
implants with high-strength silicone gel. Plast Reconstr Surg.
2012;130:973–981.
9. Maxwell GP, Van Natta BW, Murphy DK, et al. Natrelle style 410
form-stable silicone breast implants: core study results at 6 years.
Aesthet Surg J. 2012;32:709–717.
10. Hammond DC, Migliori MM, Caplin DA, et al. Mentor Contour
Profile Gel implants: clinical outcomes at 6 years. Plast Reconstr
Surg. 2012;129:1381–1391.
11. Mallucci P, Branford OA. Population analysis of the perfect breast: a
morphometric analysis. Plast Reconstr Surg. 2014;134:436–447.
12. Roostaeian J, Adams WP. Three-dimensional imaging for breast
augmentation: is this technology providing accurate simulations.
Aesthet Surg J. 2014;34:857–875.
13. Stevens WG, Nahabedian MY, Calobrace MB, et al. Risk factor
analysis for capsular contracture: a 5-year Sientra study analysis
using round, smooth, and textured implants for breast
augmentation. Plast Reconstr Surg. 2013;132:1115–1123. This review of
the largest FDA manufacturer cohort shows clearly the differences in
implant pocket, texturing and incision selections. It should be reviewed as
part of the consultative and decision making process.
14. Tebbetts JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272. The modern breast surgeon needs to
understand the power of the dual plane technique. Its facility to shape the
breast in many situations will improve any surgeons outcomes.
15. Schwartz MR. Algorithm and techniques for using Sientra’s silicone
gel shaped implants in primary and revision breast augmentation.
Plast Reconstr Surg. 2014;134:S18–S27. This is the authors preferred
technique for the evaluation, planning and procedure for breast
augmentation. Text and Video provide a clear demonstration of this
method.

SECTION I • Aesthetic Breast Surgery
3 
Device considerations in breast
augmentation
G. Patrick Maxwell and Allen Gabriel
SYNOPSIS
■ Breast augmentation is the most common aesthetic procedure
performed in the United States and perhaps in the world.
■ In preparing for a breast augmentation, one must understand each
patient’s goals and expectations and see if they can be achieved.
■ Three important variables have to be addressed prior to the surgery:
1. Incision length and placement (inframammary, periareolar,
transaxillary, transumbilical)
2. Pocket plane (subfascial, subglandular, submuscular, subpectoral
with dual plane 1, 2, 3)
3. Implant choice (saline vs. silicone, round vs. anatomic, smooth vs.
textured).
■ Biodimensional planning is utilized for preoperative exam.
Access the Historical Perspective section online at

Introduction
Glandular hypomastia may occur as a developmental
or involutional process and affects a significant number
of women. Developmental hypomastia is often seen as
primary mammary hypoplasia or as a sequela of tho-
racic hypoplasia (Poland syndrome) or other chest wall
deformity. Involutional hypomastia may develop in the
postpartum setting and may be exacerbated by breast-
feeding or significant weight loss. When compared to
the norm, inadequate breast volume may lead to a nega-
tive body image, feelings of inadequacy, and to low
self-esteem.1 These disturbances may adversely affect a
patient’s interpersonal relationships, sexual fulfillment,
and quality of life.2
There has been a steady increase in breast augmenta-
tion surgery with the emerging importance of body
image, changes in societal expectations, and the increas-
ing acceptance of aesthetic surgery. In the United States
alone, augmentation mammaplasty was performed in
over 330 000 patients in 2014 and was the most frequently
performed cosmetic surgical procedure in women.3 In
this chapter, we review the history of breast augmenta-
tion, operative planning and technique, and some
perioperative and late complications of the procedure.
The evolution of modern breast implants is described.
Basic science/disease process
Evolution of saline implants
The use of inflatable saline-filled breast implants was
first reported in 1965 by Anon in France.7 The saline-
filled implant was developed in order to allow the
non-inflated implant to be introduced through a rela-
tively small incision, and then inflating the implant in
situ.8
Saline-filled implants are manufactured with a range
of recommended fill volumes. Mild breast asymmetry
may be corrected by taking advantage of this range of
recommended fill volumes during placement of the
implants. Underfilling saline-filled implants may lead to
increased deflation rates due to folding or friction sub-
jected to the implant shell, and is not recommended.
Underfilling saline-filled implants may also lead to a
wrinkled appearance or rippling with the breast in certain
positions. Saline-filled implants have historically per-
formed better when slightly overfilled and when placed

26.e1
Historical perspective
Historical perspective
The first report of successful breast augmentation
appeared in 1895 in which Czerny described transplant-
ing a lipoma from the trunk to the breast in a patient
deformed by a partial mastectomy.4 In 1954, Longacre
described a local dermal-fat flap for augmentation of the
breast.5 Eventually, both adipose tissue and omentum
were also used to augment the breast.
During the 1950s and 1960s, breast augmentation
with solid alloplastic materials was carried out using
polyurethane, polytetrafluoroethylene (Teflon), and
expanded polyvinyl alcohol formaldehyde (Ivalon
sponge). Ultimately, the use of these materials was
discontinued after patients developed local tissue reac-
tions, firmness, distortion of the breast, and significant
discomfort.6 Various other solid and semi-solid materi-
als have been injected directly into the breast paren-
chyma for augmentation including epoxy resin, shellac,
beeswax, paraffin, petroleum jelly, and liquid silicone.
Liquid silicone (polydimethyl siloxane) was originally
developed in the aeronautics industry during World
War II. In 1961, Uchida reported the injection of liquid
silicone into the breast for breast augmentation.6 Unfor-
tunately, injection of liquid silicone resulted in frequent
complications including recurrent infections, chronic
inflammation, drainage, granuloma formation, and
even necrosis.7,8 Breast augmentation by injection of free
liquid silicone was abandoned in the United States in
light of these complications.
The modern breast implant is a two-component
prosthetic device manufactured with a nearly imperme-
able silicone elastomer shell filled with a stable filling
material, consisting of either saline solution or silicone
gel. This shell + filler implant was originally developed
by Cronin and Gerow in 1962 using silicone gel as the
filling material contained within a thin, smooth silicone
elastomer shell.9 Since that time, both silicone gel and
saline-filled implants have undergone several technical
alterations and improvements with US Food and Drug
Administration (FDA) approval of the fourth-generation
silicone implants in November of 2006.10

27
Basic science/disease process
designed under more stringent ASTM (American Society
for Testing Methodology)19 and FDA-influenced criteria
for shell thickness and gel cohesiveness. Furthermore,
they were manufactured with improved quality control20
and with a wider variety of surface textures and implant
shapes. They are currently available from all three breast
implant manufacturers in the United States (Sientra,
Allergan, and Mentor).21–25
During the same time the concept of anatomically
shaped implants was introduced with the fifth-generation
silicone gel implants.26 In addition to having a textured
surface, these anatomically shaped implants are filled
with a more cohesive gel. The FDA approved fifth-
generation implants from all of the US manufacturers in
the following order: Sientra (2012), Allergan, and Mentor
(both 2013). Each manufacturer was approved for a
variety of shapes and styles with Sientra offering five
styles of the HSC+ line, four 410 implant styles from
Allergan, and one Contour Profile Gel (CPG) implant
from Mentor.22,27,28
To further understand the evolution of silicone-
filled implants, implant characteristics will be further
reviewed, as the resultant breast form is not only depen-
dent on the soft-tissue envelope (in augmentation and
reconstruction) and the breast parenchyma (in augmen-
tation) but also on the following implant characteristics:
surface, filler, shell, and implant shape.
Surface
Surface characteristics have undergone changes and
evolved with all three manufacturers working towards
the common goal of utilizing texture to possibly mini-
mize or even disrupt capsule formation.29,30 The evolu-
tion of textured implants began with polyurethane-coated
implants reporting lower capsular contracture rates.31
These foam-coated implants were eventually removed
voluntarily from the US market because of concerns
related to difficulty associated with complete removal
and the theoretical concern of malignant transformation
associated with the polyurethane coating. Polyurethane
foams are thought to undergo partial chemical degrada-
tion under physiologic conditions releasing compounds
that could become carcinogens in experimental animals
but are not known human carcinogens.32
In the 1980s, manufacturers shifted their focus from
polyurethane-covered shells to textured silicone shells
with different pore sizes. Of all the textured surfaces
currently in use, none are created in the same manner
and each manufacturer has a proprietary process in
place. One of the critical issues during the evolution of
the texture is to find a way to stabilize the implant in
the breast pocket. Studies have demonstrated that the
under thicker soft-tissue coverage. Although these
implants may be slightly overfilled, aggressive overfill-
ing may lead to a more spherical shape and scalloping
along the implant edge with knuckle-like palpability
and unnatural firmness. Another potential disadvantage
of saline-filled implants is that the consistency of these
implants on palpation is similar to that of water instead
of the more viscous feel of natural breast tissue.
Evolution of silicone implants
The first generation silicone gel-filled implant intro-
duced in 1962 by Cronin and Gerow was manufactured
by Dow Corning Corporation.9 The shell of the first
generation implant was constructed using a thick,
smooth silicone elastomer as a two-piece envelope with
a seam along the periphery. The shell was filled with a
moderately viscous silicone gel. The implant was ana-
tomically shaped (teardrop) and had several Dacron
fixation patches on the posterior aspect to help maintain
the proper position of the implant. These early devices
had a relatively high contracture rate, due to the quality
of the shells and the lack of cohesivity of the gel, which
then encouraged implant manufacturers to develop
second-generation silicone gel-filled implants.11
In the 1970s, the second-generation silicone implants
were developed in an effort to reduce the incidence of
capsular contracture with a thinner, seamless shell and
without Dacron patches incorporated into the shell.
These implants were round in shape and filled with a
less viscous silicone gel to provide a more natural feel.
However, the second-generation breast implants were
plagued by diffusion or bleed of microscopic silicone
molecules into the periprosthetic intracapsular space
due to their thin, permeable shell and low viscosity sili-
cone gel filler. This diffused silicone produced an
oily, sticky residue surrounding the implant within
the periprosthetic capsule that was noticeable during
explantation of older silicone-filled implants.12
The development of the third-generation silicone gel-
filled implants in the 1980s focused on improving the
strength and permeability of the shell in order to reduce
silicone gel bleed from intact implants and to reduce
implant rupture and subsequent gel migration. The
manufacturers designed new implant shells that con-
sisted of multilayered silicone elastomer. These third-
generation prostheses reduced gel bleed by introducing
a barrier layer and a thicker shell that significantly
lowered the device shell failure rate.
After the FDA required the temporary restriction of
third-generation silicone gel implants from the Ameri-
can market in 1992,13–18 the fourth- and fifth-generation gel
devices evolved. These silicone gel breast implants were

28
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
exists to measure the cohesivity of the silicone gel of
commercially available devices and was utilized to
measure the stiffness of both Allergan and Mentor
shaped and round implants. This study showed that the
410 implant (Allergan Inc.) had the stiffest gel represent-
ing the highest cohesivity compared to the CPG implant
(Mentor).27 In a separate study it was found that the
Sientra form-stable implant was the least cohesive when
compared to both the CPG and 410 implants. It is impor-
tant to note that cohesivity represents only a single
characteristic of the implant, and one must take into
account various implant features in order to evaluate
the implant as a whole.27 In this same study it was
demonstrated that Allergan’s round implants were the
least cohesive as compared to Mentor’s round implants
and Sientra’s implants were the most cohesive as com-
pared to both Allergan’s and Mentor’s round
implants.
In the past, the effect of the filler material has been
shown to have an effect on capsular contracture rates.38–41
However, these studies compared the third-generation
silicone implants to saline implants, and therefore the
current implants may have other outcomes since fourth-
generation silicone breast implant safety and long-term
outcomes have been described.22,23,25,27,28
Shell
Extensive chemical cross-linking of the silicone gel
polymer will produce a solid form of silicone referred
to as an elastomer with a flexible, rubber-like quality.
Silicone elastomers are used for the manufacture of
facial implants, tissue expanders, and the outer shell of
all breast prostheses. The introduction of shell modifica-
tions, such as barrier layers and triple shell elastomer to
protect the gel, have led to safer implants.22,23,27,28,42 The
elastomeric shell characteristics are also dependent on
the relationship of the gel and shell. Shell characteristics
also depend on the thickness and how the internal gel
is bonded to the shell that leads to stability of the final
shape.
Implant shape
The maintenance of gel distribution within the shell
helps to preserve the form stability.42 The more cohesive
the gel, the higher the gel–shell fill ratio, and the more
enhanced bonding of the gel to the shell will lead to
more improved shape maintenance. The gel–shell fill
ratio varies among the manufacturers and can produce
visual clinical differences and may result in rippling and
upper pole collapse if not used in the proper patient.
It is important to note that all types of implants in
the round portfolio of US manufacturers vary in the
pore size is critical to allow for tissue adherence leading
to the “adhesive effect” and implant stabilization.33 It
was not clear if the pore size correlated with a reduction
in capsular contracture; however, it did correlate with
implant stabilization.33 Danino et al. compared the
Biocell texture with pore diameter of 600–800 µm with
a depth of 150–200 µm to Siltex pore diameter of
70–150 µm. It was noted that Siltex pores lead to no
“adhesive effect”.33
The manufacturing process of textured surface
implants can be complex while smooth surface implants
are made by dipping a mandrel into liquid silicone
creating multilayers, followed by allowing the surface
to cure in a laminar flow oven. Additional steps beyond
creating smooth surface implants are involved in the
creation of textured implants.34 Sientra’s Silimed implant
(Sientra Inc., Santa Barbara, CA), named as TRUE
Texture, avoids the use of sodium chloride, sugar, soak/
scrub, or pressure stamping.28,35,36 Small hollow pores
are formed with minimal thin cell webbing that reduces
particle formation. The Biocell (Allergan Inc., Irvine,
CA) texture is created using a “loss-salt” technique,34
which includes a layer of salt crystals with a thin over-
coat of silicone followed by curing in a laminar flow
oven.34 The Siltex surface (Mentor Corp., Santa Barbara,
CA), on the other hand, is created by “imprint stamp-
ing”,34 which dips the chuck into uncured silicone,
pushing it into polyurethane foam and finalizing the
imprint with pressure.34
Filler
Silicone is a mixture of semi-inorganic polymeric mol-
ecules composed of varying length chains of polydimethyl
siloxane [(CH3)2-SiO] monomers. The physical proper-
ties of silicones are quite variable depending on the
average polymer chain length and the degree of cross-
linking between the polymer chains.37 Liquid silicones
are polymers with a relatively short average length and
very little cross-linking. They have the consistency of an
oily fluid and are frequently used as lubricants in phar-
maceuticals and medical devices. Silicone gels can be
produced of varying viscosity by progressively increas-
ing the length of the polymer chains or the degree of
cross-linking.
When enough filler cross-linking is achieved to the
degree that the silicone gel implant will maintain its
dimensions and form (i.e., gel distribution within the
shell), the cohesive gel implant is considered to be “form
stable”, although this terminology has recently been
questioned as no gel implant on the market is truly form
stable. Form stable may more appropriately refer to the
ability of an implant to maintain shape. Technology

29
Patient selection
sloping or full upper pole and a gently curved lower
pole with the nipple areolar complex at the point of
maximal projection. The breast structure itself may be
thought of as the breast parenchyma resting on the
anterior chest wall surrounded by a soft-tissue envelope
made up of skin and subcutaneous adipose tissue.
Clearly, the resulting form of the breast after augmenta-
tion mammaplasty will be determined by the dynamic
interaction of the breast implant, the parenchyma, and
the soft-tissue envelope.44
A thorough physical examination begins with obser-
vation and careful documentation of any signs of chest
wall deformity or spinal curvature. It is imperative to
document and draw attention to any asymmetry of
breast size, nipple position, or inframammary fold (IMF)
position. Careful palpation of all quadrants of the breast
and axilla is required to rule out any dominant masses
or suspicious lymph nodes. While palpating the breast,
the surgeon should carefully assess the quantity and
compliance of the parenchyma and soft-tissue envelope.
The soft-tissue pinch test is a useful method of assess-
ment in which the superior pole of the breast is gathered
between the examiner’s thumb and index finger and
measuring the thickness of the intervening tissue. In
general, a pinch test result of less than 2 cm will often
indicate a need for subpectoral placement of the implant.
It is also important to characterize the amount, quality,
and distribution of the breast parenchyma as it may be
necessary to reshape or redistribute the parenchyma to
achieve the desired shape of the breast mound. The
elasticity of the skin should also be characterized
by observing its resistance to deflection and noting
any signs of skin redundancy or stretch marks. Both
manufacturers have developed a preoperative planning
system to facilitate patient assessment and implant
selection. In addition, the authors utilize 4D technology
to assess both the patient’s chest wall and soft-tissue
abnormalities. Chest-wall, soft-tissue asymmetries, and
combinations of both are important to identify preop-
eratively (Figs. 3.2–3.4). This tool is also utilized to
understand the patient’s perception of the desired look
by showing the outcomes of utilizing different size and
style implants. This is also then projected in the operat-
ing room for surgical planning.45
Patient selection
Precise measurements must be taken using the IMF, the
nipple areolar complex, and the suprasternal notch as
key landmarks (Fig. 3.5). The surgeon should measure
the breast width (BW) at its widest point, the breast
height (BH), and the distance from the nipple areolar
complex to the inframammary fold (N : IMF). The
gel–shell fill ratio within the different profiles (i.e., low,
moderate, high). Magnetic resonance imaging (MRI)
study showed that shell rippling is still noted in a prone
position in of one of the most cohesive form stable
implants.43 Changes in shape/form in different posi-
tions are generally not clinically significant but can be a
patient concern.
Diagnosis and patient presentation
The initial consultation for augmentation should begin
with open-ended questions about the patient’s goals and
expectations for the procedure. Patients today have often
spent some time researching the procedure either
through friends or through the internet. The surgeon
should be able to form an impression of the patient as a
well-informed, psychiatrically stable person with appro-
priately realistic expectations for the procedure. Any
concerns about the patient’s level of understanding,
unrealistic expectations, or self-esteem issues should be
fully explored prior to proceeding with surgery. A careful
medical history and physical examination is essential for
the assessment of risk factors and candidacy for breast
augmentation. Preoperative mammography is recom-
mended for patients over 35 years of age or patients of
any age with significant risk factors for breast cancer.
The ideal size and shape of the female breast is inher-
ently subjective and relates to both personal preference
and to cultural norms. However, most surgeons will
agree that there are certain shared characteristics that
represent the aesthetic ideal of the female breast form
(Fig. 3.1).These characteristics include a profile with a
Fig. 3.1  The aesthetic breast form is composed of measurable parameters. The
resultant breast form desired after surgical augmentation is determined by the
dynamic interaction between the character and compliance of the soft-tissue
envelope; the quality, volume, and consistency of the breast parenchyma; and the
dimensions, volume, and characteristics of the breast implant. This form can be
attained by the careful planning and surgical performance of a breast augmentation.
Upper pole
Slope of upper pole
Lower pole
Breast height
Projection

30
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
Fig. 3.2  Example of hard-tissue asymmetry. (A) AP view of patient. (B) AP view of patient following automated biodimensional measurements and volume characterization.
(C) View of patient’s chest from below. Red line delineating the soft-tissue envelope, and blue line the chest wall. (D) View of patient’s chest from below with
superimposed soft-tissue and chest wall outlines as mirror images with identification of chest wall asymmetry. Even though the volume is identical, the presenting anatomy
is very different.
A
B
21.7
3.2
6.0
270 cc
268 cc
3
6.6
3.3
21.7
12.7
12.5
C
D
distance from the suprasternal notch to the nipple
areolar complex (SSN : N) and the intermammary dis-
tance (IMD) should also be documented. It is often
helpful to make markings on the patient in the seated
position with a permanent marker just prior to surgery.
It is imperative to mark the original IMF and a good
idea to mark the true midline of the anterior chest.
In addition to manual measurements, 3D imaging is
available to facilitate the measurement process in addi-
tion to enhancing the patient’s overall experience by
increasing physician–patient interaction in selecting the
appropriate implant.45 The visual display of the implant
selected increases the confidence of the patient in the
results that will be achieved. The 3D imaging systems
can automatically measure and characterize both the
soft tissue and chest wall as this is an important step in
surgical planning. There are times that minor chest
wall or soft-tissue asymmetries are missed by manual
measurement and visualization. The system (Vectra,
Canfield Inc., Helena, MT) captures all of the asymme-
tries preoperatively so that appropriate preoperative
planning can be performed and the patient is advised
with an accurate informed consent.45 This system is
based on the biodimensional principles as previously
described. As we continue to pursue increased patient
safety and satisfaction while decreasing re-operation
rates, this system will serve as another tool in our arma-
mentarium to achieve these goals. This serves as an
excellent consultation tool to be able to better under-
stand what the patient expectations are with respect to
choosing the size and the shape of the implant.
Informed consent
It is incumbent on the surgeon to evaluate the patient’s
emotional state, timing, and appropriateness of the
desired outcome. It is the surgeon’s responsibility to
listen, educate, and evaluate; this process and the

Fig. 3.3  Example of soft-tissue asymmetry. (A) AP view of patient. (B) AP view
of patient following automated biodimensional measurements and volume
characterization. (C) View of patient’s chest from below. Red line delineates the
soft-tissue envelope, and blue line the chest wall. (D) View of patient’s chest from
below with superimposed soft-tissue and chest wall outlines as mirror images with
identification of soft-tissue asymmetry.
A
80 cc
162 cc
3.2
4.0
20.7
21.0
3.2
6.7
6.7
B
80 cc
162 cc
13.0
13.1
C
D
80 CC
162 CC
Fig. 3.4  Example of hard- and soft-tissue asymmetry. (A) AP view of patient.
(B) AP view of patient following automated biodimensional measurements and
volume characterization (C) View of patient’s chest from below. Red line delineates
the soft-tissue envelope, and blue line the chest wall. (D) View of patient’s chest
from below with superimposed soft-tissue and chest wall outlines as mirror images
with identification of soft-tissue and hard tissue asymmetry..
A
B
2.3
5.7
5.6
18.7
3.8
3.8
18.1
194 cc
271 cc
11.1
11.4
C
D

32
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
communication that takes place between patient and
surgeon are documented in the medical record. Informed
consent is not simply the signing of a paper or contract
but refers to the entire process between patient and
physician as well as physician extenders. To be
“informed”, the patient must be provided with adequate
information about risks, benefits, and treatment alterna-
tives to the proposed procedure. The authors recom-
mend the use of official American Society of Plastic
Surgeons (ASPS) informed consents. To “consent”, the
patient must be an adult (by age), be capable of rational
communication, and be able to understand the informa-
tion. The informed consent documentation must be
thorough and specific to the operation and preferably
the surgeon. A checklist of specifics (which must be
initialed by the patient) is considered advisable. “Before
and after” photographs may be shown but should be
realistic. Photographs of the patient are a necessary
form of documentation, requiring appropriate permis-
sion. Their confidentiality is essential unless permission
is given for any use other than medical review docu-
mentation. A male surgeon should be accompanied by
a female chaperone during all breast photography and
examinations. Because of the multiple options in breast
augmentation surgery, a second office visit is advisable.
There must be a clear understanding (which is docu-
mented in the medical record) between patient and
surgeon of the specific desired outcome (size, shape),
the alternative ways by which this can be achieved, and
the risk-to-benefit ratio of the chosen “pathway”.
Fig. 3.5  Preoperative measures (taken before breast augmentation) include SSN to
N (suprasternal notch to nipple), N to IMF (nipple to inframammary fold), BW
(breast width), BH (breast height), and IMD (intermammary distance).
6611
6611
1,0)
,0'
%+
%:
Operative planning
Incision length and placement
Four types of incision are commonly employed in breast
augmentation: transaxillary, inframammary, periareolar,
and transumbilical. After implant selection, the patient
and surgeon should make the decision as to which type
of incision is to be used after the options, risks, and
benefits of each have been thoroughly explained. Sur-
geons should offer only the techniques that they are
comfortable performing. The final choice should allow
the surgeon optimal control and visualization to deliver
the desired outcome for the specific patient and the
specific implant.
The inframammary incision permits complete visual-
ization of either the subpectoral or subglandular pocket
and allows precise placement of virtually all implants.
The technique does leave a visible scar within the infra-
mammary fold. Smaller incisions (<3 cm) can be used
for saline-filled implants, but silicone gel implants often
require incisions up to 5.0–6.0 cm in length. The incision
should be placed in the projected inframammary fold
rather than in the existing fold to avoid visibility and
widening of the subsequent scar. There are a variety of
techniques described for identifying the expected IMF,
and these are discussed in different chapters that discuss
use of the fifth-generation gel devices.
The periareolar incision is placed at the areolar–
cutaneous juncture and generally heals inconspicuously
in lightly pigmented patients. The dissection allows
easy adjustment of the inframammary fold and direct
access to the lower parenchyma for scoring and release
when a constricted lower pole is present. Disadvantages
include limited exposure of the surgical field, transec-
tion of the parenchymal ducts (which are often colonized
with Staphylococcus epidermidis), potentially increased
risk of nipple sensitivity changes, and visible scarring
on the breast mound. This technique should not rou-
tinely be used on patients with an areola diameter less
than 40 mm and may not allow introduction of larger
gel or enhanced cohesive gel implants. There have been
some reports of possibility of increased capsular con-
tracture rates with the use of this incision.
The transaxillary approach can be performed either
bluntly or with the aid of an endoscope. The endoscope
allows precise dissection and release of the inferior
musculofascial attachments of the pectoralis major as
well as direct visualization for hemostasis. This approach
avoids any scarring on the breast mound and can be
used with both saline and gel implants in either a sub-
pectoral or subglandular pocket. Disadvantages include

33
Operative planning
textured implants are placed in the appropriate pocket
as determined by soft-tissue thickness. Pockets for these
implants are made only minimally larger than the
footprint of the device to minimize displacement or
malrotation.
When subpectoral pockets are selected, one generally
divides the origin of the pectoralis major muscle just
above the inframammary fold to allow better projection
in the lower pole of the augmented breast and to
difficulty with parenchymal alterations and the probable
need for a second incision on the breast mound for
revisionary surgery. Precise implant placement can be
more difficult with this incision, and enhanced cohesive
gel and anatomic implants may be precluded.
Transumbilical breast augmentation has the obvious
advantage of a single, well-hidden, remote incision. It
can be used only with saline implants, however, and
precise pocket dissection requires experience. The
pocket is dissected bluntly, and hemostasis can be dif-
ficult from the remote access port. As with the transaxil-
lary approach, revisions often necessitate a second
incision on the breast mound.
Pocket position
The decision of subglandular/subfascial or subpectoral
implant placement depends on implant selection (fill
and texture) and tissue thickness (Fig. 3.6). In theory, the
best position for a mammary implant is in the subglan-
dular plane. This is the most anatomically correct posi-
tion to maintain natural shape and form. The authors,
however, no longer utilize the subglandular plane and
instead prefer the subfascial plane. The reasons for
placement of implants in the subpectoral plane are to
minimize the risk of implant visibility and palpability.
Risk of capsular contracture in either plane is dependent
on surgical preparation and technique and not necessar-
ily the pocket. With sound surgical techniques and
appropriate postoperative management, capsular con-
tracture can be minimized in either pocket. The authors’
belief is that the subfascial pocket is more superior to
subglandular, as this provides an additional durable
layer between the implant and the gland.
The subfascial implant position has been advocated
for augmentation mammaplasty in certain patients46–50
(Fig. 3.7). Theoretically, placement of the implant in the
subfascial position between the anterior fascia of the
pectoralis major and the muscle itself may provide
additional support to the overlying soft-tissue envelope,
causing less distortion of the breast form and decreasing
mobility of the implant within the pocket. The long-
term outcome studies of breast augmentation employ-
ing this position are not yet available, but the procedure
is gaining popularity worldwide.47
In patients with a pinch test result of more than 2 cm,
the implant can safely be placed in the subfascial plane.
Textured implants are the preferred implant for subfas-
cial placement. If one chooses smooth gel implants for
the subfascial plane, additional measures to prevent
capsular contracture must be taken. These include larger
pocket dissections with displacement exercises or pos-
sible dilute steroid pocket irrigation. Anatomic-shaped
Fig. 3.6  (A,B) When ample soft tissue is present, implants may be placed in the
subglandular position or subfascial position. When there is soft-tissue inadequacy,
the subpectoral position is generally preferable.
$
5RXQGLPSODQW
%
$QDWRPLFLPSODQW

34
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
to cover less of the implant with a resultant greater
subglandular implant coverage. Alternatively, the pec-
toral muscle can be divided at a higher level to give a
similar result (Fig. 3.9). These pocket manipulations
have been described as dual-plane maneuvers to allow
varying degrees of subpectoral to subglandular implant
coverage.44 This dual-plane dissection allows the pecto-
ralis muscle to retract superiorly or window-shade
maintain a natural inframammary fold (Fig. 3.8). This
places the superior portion of the implant in a subpec-
toral position while the inferior portion is subglandular.
In constricted breasts (tuberous breasts) or ptotic breasts,
for which more parenchymal surgical manipulation is
necessary, or when there is a greater need for the implant
to fill out the lower soft-tissue envelope, more dissection
between parenchyma and muscle will allow the muscle
Fig. 3.7  Preoperative and postoperative views of 39-year-old female with style 410 implants at 12 months. (A,C,E) preoperative view, FF 425 cc. (B,D,F) Postoperative, FF
425 cc in a dual-plane location.
A
B
C
D
E
F

35
Operative planning
decision between a saline-filled prosthesis and a silicone
gel implant is one of the patient’s preferences after the
surgeon’s conveyance of information. Experience has
shown the results of silicone gel implants in primary
breast augmentation to be generally soft and to have a
natural feel and appearance, assuming capsular con-
tracture is not present. Although the authors prefer
silicone gel implants, saline implants placed in the
upward while the breast parenchyma is redraped over
the inferior portion of the implant avoiding deformity
of the resulting augmented breast (Fig. 3.10).
Implant selection: filling material
In the US, there are two implant materials from which
to choose – saline- and silicone-filled implants. The
Fig. 3.8  Preoperative and postoperative views of 36-year-old female with style 410 implants at 12 months. (A,C,E) Preoperative view, MM 360 cc. (B,D,F) Postoperative,
MM 360 cc in a dual-plane position.
A
B
C
D
E
F

36
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
patient. The addition of shaped devices has given
another option for patients to choose an implant that is
more natural appearing.51
Implant selection: implant size
The selection of the implant size is initiated during the
preoperative consultation period based on both the
patient’s goals and the surgeon’s assessment. In general,
subpectoral position can produce good results with a
low incidence of capsular contracture. The thicker the
soft tissue under which a saline implant is placed, the
better it performs. Despite our preference for silicone
gel, some patients will undoubtedly continue to have
concerns about silicone-filled devices, and subpectoral
saline implants have proved to be a reasonable alterna-
tive. Ultimately, the patient must feel comfortable with
the implant device, so the final decision rests with the
Fig. 3.9  Preoperative and postoperative views of 51-year-old female with style 410 implants at 24 months. (A,C,E) Preoperative view, FF 375 cc. (B,D,F) Postoperative, FF
375 cc in a dual-plane position.
A
B
C
D
E
F

37
Operative planning
width. In this way, the surgeon should be able to attain
the desired amount of projection while preserving the
normal aesthetic proportions of the breast (Fig. 3.11).
The patient’s request for a particular breast size and
shape will largely determine the dimensions of the
breast implant used. In addition to a thorough discus-
sion with the patient as to her desire for the resultant
form and size, the 4D imaging system can be utilized to
show the patient the outcomes based on the selection of
a particular implant.
Implant selection: implant surface texture
The decision between textured and smooth-walled
implants is only applicable for round implants. Ana-
tomic implants are all textured by design to minimize
malrotation (Fig. 3.12). With round implants, the choice
the critical factors in selecting a specific implant size are
the dimensions of the nascent breast, the compliance
and characteristics of the soft-tissue envelope, and the
desired volume for the resulting augmented breast.
The base width of the breast is related to the width of
the patient’s chest and is proportional to the overall
body habitus. It is imperative that this dimension is
respected during augmentation in order to maintain the
normal anatomical landmarks such as the lateral breast
fold in the anterior axillary line and the intermammary
distance (IMD). The same is true for breast height, but
to a lesser degree than breast width. Violation of these
landmarks may yield an unnatural and deformed
appearance. Generally, the surgeon should select an
implant that is slightly less wide than the existing breast.
Implant manufacturers are now producing implants
with varying degrees of projection for a given base
Fig. 3.10  Subpectoral implant placement generally involves release or division of the pectoralis major muscle, resulting in varying coverage relationships of muscles and
parenchyma to implant. (A,D) For most routine breasts: muscle division near the inframammary fold results in muscle coverage of most of the implant. (B,E) Breasts with
mobile parenchyma muscle interface: muscle division (or muscle–parenchymal detachment) to the lower areolar level results in muscle coverage of the upper half of the
implant. (C,F) Breasts with glandular ptosis or lower pole constriction: muscle division (or muscle–parenchymal detachment) to the upper areolar level results in muscle
coverage of the upper third of the implant.
$
%
&
'
(
)

38
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
between textured and smooth-walled implants is based
primarily on minimizing capsular contracture. For
subpectoral augmentation, either implant can probably
be used with comparable results. When the device is
placed in the subfascial pocket, a textured implant is
preferred to minimize capsular contracture. If a smooth-
walled implant is chosen, then the dissected pocket
should be large enough to accommodate the implant
displacement exercises (Fig. 3.13).
Implant selection: implant shape
It is important to reiterate the principle that the shape
of the natural female breast is not a semicircle or a
hemisphere. Dimensional analysis of the aesthetically
pleasing breast form reveals a gently sloping upper pole
and a curved lower pole with the nipple areolar complex
at the point of maximum projection. The typical round
shaped breast implant has its greatest projection cen-
trally with the remainder of the volume distributed
evenly along the base of the implant. In contrast, ana-
tomically shaped breast implants have a flatter upper
Fig. 3.11  After the width of the existing breast is measured and the desired
resultant breast form is formulated, an implant is selected (generally just narrower
than the original breast, shown on the patient’s right) that in combination with the
preoperative breast tissue will achieve the desired postoperative dimensions and
form (shown on the patient’s left).
Original
breast width
Resultant
breast width
Implant width
13cm
14.5cm
12.5cm
Fig. 3.12  Preoperative and postoperative views of 40-year-old female with style 410 implants at 12 months. (A,C) Preoperative, FM 270 cc. (B,D) Postoperative, FM
270 cc in a dual-plane position.
A
B
C
D

39
Treatment and surgical technique
position as often as needed during the procedure. The
sterile preparation and draping of the anterior chest
must provide visualization of the patient’s shoulders as
an important anatomical reference point. Triple antibi-
otic solution irrigation will be used for all implant cases
regardless of the incision type.
pole with the majority of the volume and projection in
the lower pole (Fig. 3.14). Thus, the anatomically shaped
implant of a given base width and volume will produce
less upper pole convexity than a round implant of the
same base width and volume (Fig. 3.15). This character-
istic of anatomically shaped implants can be extremely
useful when the patient desires a significant volume
augmentation but has a relatively narrow breast width.26
Treatment and surgical technique
Preoperative markings are made with the patient in the
upright position and are useful as a reference point
during the actual procedure. The surgeon should mark
the chest midline in the frontal view from the supraster-
nal notch to the xiphoid process, the existing inframam-
mary folds, and the likely position of the new
inframammary folds as the proposed limits of the dis-
section. The patient is then asked to place her arms
behind her head to visualize the displacement of the
nipple and the true inframammary fold. The “yoga”-
type stretching exercises are also reviewed with the
patient at this point. Following review of the consent
and the plan, the patient is taken to the operating room.
The patient is then placed in the supine position, cen-
tered on the operating table with the pelvis directly over
the flexion point of the bed. The arms must be well
secured to the arm boards that are placed at 90-degree
angles to the torso. These preparations are required so
that the patient may be placed in the upright seated
Fig. 3.13  Pocket dissection.
Mobile implant moving
within larger capsule
Hints and tips
• It is imperative that dimensions are respected during
augmentation in order to maintain the normal anatomical
landmarks such as the lateral breast fold in the anterior
axillary line and the intermammary distance (IMD).
• The patient’s request for a particular breast size and shape
will largely determine the dimensions of the breast implant
used.
• The implant pocket is irrigated with an antibiotic solution
containing 50 000 units of bacitracin, 1 g of cefazolin, and
80 mg of gentamicin per 500 mL of saline.
• Immediate stretching exercises are utilized postoperatively.
Inframammary incision
The inframammary approach permits complete visual-
ization of the implant pocket with either subglandular,
subfascial, or subpectoral placement. The incision
should be placed in the predicted location of the new
inframammary fold that has been determined and
marked preoperatively. Smaller incisions (<3 cm) may
be used for inflatable saline-filled implants, but pre-
filled implants (silicone gel or saline) often require
incisions up to 5.0 cm in length. The incision should be
designed with the majority of the incision lateral to the
breast midline as this will place the resulting scar in the
deepest portion of the new IMF.
The incision is made along the proposed markings,
and the dissection is continued with an insulated elec-
trocautery instrument through Scarpa’s fascia. A fiber-
optic headlight is worn throughout the procedure, or a
variety of lighted fiberoptic retractors are available to
aid illumination and direct visualization within the
pocket. If the implant is to be placed in the subfascial
pocket, the dissection proceeds below the pectoralis
fascia but above the pectoralis major fascia. Once the
fascia is identified, it will be thicker as dissection pro-
ceeds more cephalad. Several medial intercostal perfo-
rating vessels may be encountered. These should be
avoided or coagulated with insulated forceps if need be.
For smooth-walled implants, a larger pocket is dissected
to allow mobility of the implant. For anatomic implants,
the pocket is precisely dissected to snugly accommodate
the implant. Care should be taken to preserve the lateral
intercostal cutaneous nerves, especially the fourth

40
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
used to complete the dissection. The inferior origin of
the pectoralis major is released from lateral to medial
at the level of the inframammary fold. Various slips
of origin of the pectoralis major muscle are generally
encountered and divided. Division of the pectoralis
continues medially to the sternal border. Partial deep
division may selectively be carried out 1–3 cm above
the xiphoid, depending on which implant is to be used.
Lateral dissection can be done bluntly with a finger to
intercostal, which contains the primary sensory inner-
vations of the nipple areolar complex.
If a subpectoral pocket is chosen, the dissection is
initially carried out laterally to identify the lateral
border of the pectoralis major muscle. The muscle edge
can be lifted by forceps to allow easy entry into the
submusculofascial plane. This plane is readily identified
by the wispy areolar connective tissue and ease of
dissection. An extended electrocautery instrument is
Fig. 3.14  Preoperative and postoperative views of 24-year-old female with style 15 implants at 24 months. (A,C,E) Preoperative, 286 cc. (B,D,F) Postoperative, 286 cc in
a dual-plane position.
A
B
C
D
E
F

41
Treatment and surgical technique
are carefully dissected to prepare the pocket. In addi-
tion, if a dual-plane pocket is planned preoperatively,
further dissection over the muscle is carried out
pending the level of the desired dual plane followed
by release of the pectoralis major at the inframammary
fold.
Exact implant “sizers” (gel or saline) are used when
available to evaluate the pockets and resultant breast
form. After the sizers are in place, the patient is placed
avoid injury to the lateral neurovascular bundles. The
nerves can be stretched to accommodate the implant
but should be preserved to minimize postoperative
sensory changes. When the pectoralis major muscle is
elevated, care must be taken to leave the pectoralis
minor down on the chest wall. This will minimize
bleeding and allow proper placement of the implant.
At times, one may encounter several muscle interdigita-
tions between the pectoralis minor and major, and these
Fig. 3.15  Preoperative and postoperative views of 36-year-old female with style 15 implants at 24 months. (A,C,E) Preoperative, 371 cc. (B,D,F) Postoperative, 371 cc in
a dual-plane position.
A
B
C
D
E
F

42
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
breast parenchyma to the pectoralis major fascia. The
dissection is the same as described through the inframa-
mmary incision. If the inferior pole of the breast is
constricted, radial scoring of the gland in the inferior
pole can allow proper redraping of the soft tissue over
the implant to correct the deformity. Before final implant
placement, the pocket is once again checked for hemo-
stasis and irrigated with an antibiotic solution. The
closure is particularly important with this technique.
The gland must be precisely reapproximated and closed
with several layers of interrupted absorbable sutures to
prevent distortion of the nipple areolar complex. The
skin is closed with deep everting dermal sutures and a
running subcuticular absorbable monofilament. Steri-
Strips are applied to the closed incision.
Transaxillary incision
The transaxillary approach was described by Hoehler in
1973 and popularized by Bostwick and others.53 This
procedure can be performed either bluntly using the
Montgomery dissector, or using an endoscope for
precise visualization, and dissection of the implant
pocket. The transaxillary approach avoids incisional
scarring directly on the breast and places the incision in
the inferior and anterior area of the axilla. The transaxil-
lary incision usually provides adequate access when
placing an inflatable round breast implant and, while
not precluding, is more difficult for placement of a large
pre-filled implant or an anatomically shaped device.
The markings for transaxillary breast augmentation are
also made with the patient in the sitting or upright
position. The existing and resultant inframammary
folds are marked, as are the boundaries of the proposed
dissection. To locate and mark the incision, the patient’s
arm is placed in complete adduction and the most
anterior aspect of the axilla is marked. The incision
should not extend beyond this line. The arm is then
abducted approximately 45°, and a prominent axillary
crease is identified. Any fold may be used, but prefer-
ence is given to one high in the axilla, which aids in
instrumentation during the procedure. For saline-filled
implants, the incision should generally be 2.5–3.5 cm.
Silicone implants require larger incisions. The patient is
placed on the operating table in the supine position with
arms abducted 90° and secured to arm boards that allow
10- to 15-degree variations in abduction and adduction
from 90°. She must be able to flex 90° at the waist during
the procedure. The incision is made, and small sharp
retractors are used to elevate the medial aspect of
the incision. Superficial subcutaneous dissection to the
lateral border of the pectoralis major prevents injury
to the intercostobrachial nerve. Scissor dissection is
in a 90-degree upright position and evaluated from
various perspectives. Any asymmetry or under-dissected
areas are marked, and the patient is placed back in the
supine position. Once adequate hemostasis is obtained
and pocket dimensions are finalized, the pocket is irri-
gated with an antibiotic-containing solution,52 and the
implants are carefully placed by a minimal-touch tech-
nique.52 The final results are assessed, again with the
patient in a sitting position, and a multilayer closure is
performed with absorbable suture. It is important to
close off the implant pocket with a separate layer of
suture before closing the skin. Once closure is complete,
Steri-Strips are applied along the direction of the
incisions.
Hints and tips
• Exact implant “sizers” (gel or saline) are used when
available to evaluate the pockets and resultant breast form.
Periareolar incision
The periareolar approach for augmentation mamma-
plasty was described by Jenny in 1972 and currently
enjoys widespread use by plastic surgeons.7 The peri-
areolar incision is placed along the inferior portion of
the areolar–cutaneous juncture. The principle advantage
of this incision is that the resulting scar is usually well-
camouflaged and quite inconspicuous. The periareolar
approach allows easy adjustment of the IMF and direct
access to the parenchyma for scoring and release when
the lower pole of the breast is constricted. However,
visualization and the dissection are typically inadequate
with the periareolar incision in patients with areolas less
than 3 cm in diameter. Other disadvantages of this
approach include the potential risk of contamination if
the lactiferous ducts are transected, the increased risk of
changes in nipple sensitivity, and the risk of a hypopig-
mented scar in patients with darkly pigmented areolas.
The markings for a periareolar approach are similar
to those for an inframammary augmentation. The inci-
sion is marked along the junction of the areola and the
breast skin. The limits of the incision are the 3-o’clock
and 9-o’clock positions.
The positioning of the patient is identical to that for
an inframammary approach. It is imperative that the
patient be able to fully flex at the waist for evaluation
of the intraoperative appearance of the implants.
The precise incision is made. Wound edges are ele-
vated directly up from the chest wall with an opposing
pair of small sharp retractors. An insulated electrocau-
tery unit is used to dissect straight down through the

43
Complications
manual external pressure. The expander is filled with
saline to 150% of the final volume of the implant. Pocket
adjustments can be made manually during filling. When
the expansion is complete, the expander is drained and
removed from the pocket by traction on the fill tube. The
implant is placed and filled in exactly the same manner
as the expander. The endotube is then replaced, and an
endoscope may be used to verify implant position,
valve patency, and hemostasis. The incision is closed
with a single layer of absorbable suture. An abdominal
binder is used for compression on the abdominal
tunnels.
Postoperative care
In the overwhelming majority of cases, augmentation
mammaplasty is performed as an outpatient procedure.
Patients are given prescriptions for oral analgesics and
a 3-day course of prophylactic oral antibiotics. The
patient is shown yoga-type stretching exercises of the
chest to be performed on the same day following her
surgery. Patients are allowed to remove operative dress-
ings and shower as desired starting on postoperative
day one. The first follow-up visit is scheduled for 1–3
days after the procedure. If smooth (non-textured)
implants were used, initiation of implant mobility exer-
cises is recommended at this time. If the patient is at risk
for superior implant displacement, a circumferential
elastic strap may be used to apply continuous down-
ward pressure during the early postoperative period.
Patients are usually able to return to work a few days
after surgery, but are not permitted to resume rigorous
exercise for 2–3 weeks. Additional follow-up visits are
scheduled at 4–6 weeks, 3 months, and 1 year. The
importance of postoperative photo documentation and
critical analysis of the operative outcomes cannot be
overemphasized. It is the author’s practice to place
patients on vitamin E 400 IU once a day for two years
to minimize capsular contracture. Although there are no
evidence-based studies in the augmentation population
on the use of vitamin E, there is encouraging evidence
in the treatment of radiation-induced fibrosis (RIF) in
mastectomy patients with radiation-induced morbidi-
ties related to scarring.54
Complications
Perioperative complications
Alterations of nipple sensitivity after augmentation
mammaplasty may be manifested as either anesthesia
or hyperesthesia and are thought to result from traction
injury, bruising, or transection of the lateral intercostal
employed with use of the electrocautery and insulated
forceps to control any bleeding. The fascia of the pecto-
ralis major muscle is visualized at the lateral edge of the
muscle, and the dissection is carried deep to this for a
subfascial placement or deep to the muscle for subpec-
toral placement. One must be certain the correct plane
is entered before continuing the dissection further.
For an endoscopically assisted augmentation, the
endoscope is passed into the transaxillary tunnel, and
the subpectoral space is seen under direct vision. This
allows a more controlled release of the pectoralis major
origin with a long insulated electrocautery instrument.
On completion of the dissection, implant sizers are used
to evaluate the pocket and identify any areas that need
final adjustment. This must be done with the patient in
the sitting position. The pockets are then irrigated with
an antibiotic solution,52 and the final implants are
inserted. Before closure, the patient is once again placed
in the sitting position for a final check of the implant
position. The pectoralis muscle fascia is repaired with
a single absorbable suture, and the incision is closed
in one or two layers. Steri-Strips are applied to the
incision.
Transumbilical
The markings for transumbilical breast augmentation
are similar to those for a standard inframammary fold
approach. The patient is placed on the operating table
in the same manner as for an inframammary augmenta-
tion. An additional mark is made with the patient
supine: a line is drawn from the umbilicus to the medial
border of the areola bilaterally. An incision is made
within the umbilicus, large enough to easily accom-
modate an index finger. An endotube with a blunt
obturator is passed just above the rectus fascia along the
line from the umbilicus to the areola. Care is taken to
constantly palpate the progress of the obturator with the
surgeon’s other hand, always keeping the force up and
away from the abdominal and thoracic cavities. The
endotube is advanced over the costal margin. For sub-
glandular implant placement, the force applied to the
endotube is directed upward at the inframammary fold
to prevent the obturator from slipping beneath the
pectoralis major. The tunnel ends just cephalad to the
nipple. Subpectoral positioning is possible by careful
technique with use of special instruments to enter the
fascial plane high laterally. The obturator is then
removed, and an endoscope may be used to verify
correct pocket identification. Hemostasis is also ensured.
Both the endotube and endoscope are removed from the
tunnel, and an expander is rolled up and placed within
the incision. The expander is “milked” up the tunnel by

44
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
Table 3.1  Herbs, herbal teas, homeopathic medicines, and dietary supplements associated with an increased risk of bleeding
Supplement
type
Supplement
name(s)
Treatment uses
Other side effects
(in addition to intrinsic
bleeding risks)
Perioperative
recommendations
Herbs and
herbal
extracts
Garlic
  Allium sativum
  Ajo
Hypertension,
hypercholesterolemia, fungal
infections, cancer, MI
prevention, PVD
Nausea, vomiting,
hypoglycemia, halitosis,
potentiation of warfarin,
increased INR, abdominal
pain, diarrhea, oral ulcers,
anaphylaxis (rare)
Discontinue 7 days before
surgery7
Resume 7 days after
surgery
Ginger
  Zingiber officinale
Nausea, vomiting, GI bloating,
dyspepsia, OA, RA,
migraine, homeostasis
restoration, weight loss
Nausea, GI bloating, worsen
cholecystitis, arrhythmia
(possible), hypoglycemia
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Ginseng
  Panax ginseng
Stimulant, nausea, cancer
prevention, CAD, DM2,
dyspepsia, colic, infections,
aging, stress, homeostasis
restoration
Nausea, diarrhea,
headaches, hypotension,
hypertension, breast
tenderness,
hypoglycemia, insomnia
(possible), interaction with
warfarin
Discontinue 7 days before
surgery7,30
Resume 2 weeks after
surgery
Ginkgo
  Ginkgo biloba
  Maidenhair tree
Circulatory stimulant, dementia
(Alzheimer’s, multi-infarct),
memory enhancement, PVD,
ED
Nausea, vomiting, diarrhea,
GI discomfort, headaches,
palpitations, potentiates
warfarin
Discontinue 36 hours or
more before surgery7
Resume 7 days after
surgery
Feverfew
  Tanacetum
parthenium
Fever, migraine, OA, GI upset,
infertility
Oral ulcers, allergic
reactions, GI discomfort
and bloating
Taper and discontinue by
2–3 weeks before surgery
to avoid withdrawal
syndrome with abrupt
cessation52
Resume 2 weeks after
surgery
Bromelain
Inflammation, OA, autoimmune
disorders, menstrual pain,
digestion, gout
GI discomfort, diarrhea,
tachycardia, menorrhagia
(possible)
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Liquorice/licorice
  Glycyrrhiza glabra
Aphthous ulcers, peptic ulcers,
cancer, OA, adrenal
insufficiency
Hypokalemic paralysis,
hypertension, weight loss/
gain, infertility, temporary
vision loss
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
cutaneous nerves. The incidence and severity of nipple
sensation changes does not vary with the surgical
approach employed.55
Periprosthetic seroma fluid is usually resorbed by the
soft tissues within the first week of surgery, and use of
topical antibiotics intraoperatively has been shown to
decrease the rates.56 The authors do not use drains for
primary breast augmentation.
The development of a hematoma after breast aug-
mentation has several deleterious effects in both the
early and late postoperative period including pain,
blood loss, disfigurement, and capsular contracture.57
Preoperatively, patients should receive a list of prescrip-
tion and over-the-counter medications that may
contribute to excessive postoperative bleeding. It is
imperative that patients discontinue any medications
and herbal supplements that impair clotting or platelet
function at least one week prior to surgery44,45 (Table
3.1). If a hematoma does develop in the perioperative
period, immediate evacuation of the hematoma and
exploration of the pocket is recommended. Unfortu-
nately, the source of the hematoma is only rarely identi-
fied at the time of the exploration. Patients may
occasionally present with a delayed hematoma 1–2
weeks or even months to years after augmentation, and
frequently a history of breast trauma is elicited. Expand-
ing hematomas require exploration and drainage
regardless of the length of time from the augmentation.

45
Complications
Table 3.1  Herbs, herbal teas, homeopathic medicines, and dietary supplements associated with an increased risk of bleeding—cont’d
Supplement
type
Supplement
name(s)
Treatment uses
Other side effects
(in addition to intrinsic
bleeding risks)
Perioperative
recommendations
Red chili pepper
  Capsaicin
Analgesic, chronic neuropathy,
OA, uremic pruritus,
psoriasis
Burning and stinging on
contact, hypoglycemia,
cough
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Saw palmetto
  Serenoa repens
BPH, urinary tract infections
Nausea, vomiting, diarrhea,
rhinitis, decreased libido,
headache
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Oil of wintergreen
  Methyl salicylate
OA, joint discomfort,
hypertension, inflammation,
cellulite, flavoring agent
Displaces warfarin, nausea,
vomiting, dizziness,
increased INR
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Devil’s claw
  Harpagophytum
procumbens
Analgesic, fever, digestion aid,
OA, appetite stimulant
Diarrhea, GI discomfort,
tinnitus, headache,
hypoglycemia, arrhythmia
(possible)
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Chinese agrimony
  Agrimonia pilosa
Analgesic, bacterial infection,
helminthic infection, diarrhea,
inflammation, cough, sore
throat
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Danshen
  Salvia miltiorrhiza
Atherosclerosis, stroke,
angina pectoris,
hypercholesterolemia,
cancer, HIV, menstrual
disorders, OA, insomnia,
prostatitis
Hypotension, GI discomfort,
reduced appetite, pruritus,
seizures (possible),
potentiates warfarin
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Baical skullcap root
  Scutellaria
baicalensis
Anxiety, inflammation, cancer,
seizures, infections,
insomnia, dysentery,
diarrhea, rabies, menstrual
disorders
Hepatotoxicity, pneumonitis
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Geum japonicum
Diuretic, astringent, CAD,
hypercholesterolemia
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Chinese peony
  Paeoniae rubra
Inflammation, GI discomfort,
spasm
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Poncitrin
  Poncirus trifoliata
Constipation, diarrhea, spasm,
expectorant
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Fritillaria bulbs
  Fritillaria cirrhosa
Spasm, expectorant,
hypertension, cough,
asthma, opium toxicity
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Japanese honeysuckle
  Lonicera japonica
Fever, headache, cough, sore
throat, bacterial infection,
inflammation, ulcers
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Continued

46
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
Nonoperative management of small nonexpanding
hematomas is one option, but places the patient at
a higher risk of subsequent periprosthetic capsular
contracture.
Postoperative wound infection may present with a
spectrum of severity ranging from a mild cellulitis of
the breast skin to a purulent periprosthetic space infec-
tion. The organism Staphylococcus epidermidis is part of
the normal skin flora and is the most frequently identi-
fied pathogen in postoperative wound infections.
Patients are given prophylactic antibiotics intraopera-
tively and postoperatively to reduce the risk of infection.
Sterile technique is maintained during the procedure
and the implant pocket is irrigated with an antibiotic
solution containing 50 000 units of bacitracin, 1 g of
cefazolin, and 80 mg of gentamicin per 500 mL of
Table 3.1  Herbs, herbal teas, homeopathic medicines, and dietary supplements associated with an increased risk of bleeding—cont’d
Supplement
type
Supplement
name(s)
Treatment uses
Other side effects
(in addition to intrinsic
bleeding risks)
Perioperative
recommendations
Herbal formulas
Kangen-karyu
Hypertension, arteriosclerosis,
memory impairment,
headache
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Bak foong pill
GI disturbances, cardiovascular
disturbances, gynecological
dysfunction
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Herbal teas
Te gastronol
GI ulcers, intestinal
inflammation, colitis,
gastritis, flatulence
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Seasonal tonic
Appetite suppressant
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Homeopathic
medicines
and other
dietary
supplements
Guīlinggāo
  Tortoise jelly
Fever, acne, enhancing
circulation, improving
intestinal function,
constipation
None documented
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Vitamin E
Peyronie’s disease, bladder
cancer prevention, RA,
Alzheimer’s disease, PMS,
movement disorders
Allergic reaction, fatigue,
weakness, headache,
nausea, diarrhea, vision
disturbance, congenital
heart defects in utero,
heart failure
Discontinue 2–3 weeks
before surgery*
Resume when healing is
complete3
Arnica montana
  Leopard’s bane
  Wolf’s bane
OA, sprains, joint pain,
inflammation
Gastroenteritis
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Fish oil
  Eicosapentaenoic
acid
Hypertension,
hypertriglyceridemia, RA,
angina pectoris,
atherosclerosis
Hemorrhagic stroke, GI
disturbances and
bloating, diarrhea,
hyperglycemia (possible)
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Chondroitin
OA
Nausea, diarrhea,
constipation, GI
disturbances
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
Glucosamine
OA
Hypoglycemia, nausea,
diarrhea, headache,
insomnia, GI disturbances
Discontinue 2–3 weeks
before surgery*
Resume 2 weeks after
surgery
CAD, coronary artery disease; DM2, diabetes mellitus Type II; ED, erectile dysfunction; GI, gastrointestinal; HIV, human immunodeficiency virus; INR, International
Normalized Ratio; MI, myocardial infarction; OA, osteoarthritis; PVD, peripheral vascular disease; RA, rheumatoid arthritis. See also references 67-71.

47
Complications
saline.52 Further reduction of risk for bacterial contami-
nation may be achieved by employing the no-touch
technique in which only the surgeon handles the implant
with fresh, powder-free gloves. The implant is then
inserted through a sterile sleeve to minimize contact
with the patient’s skin and inflated using a sterile closed
filling system. A significant number of postoperative
wound infections will respond to oral or intravenous
antibiotics if therapy is initiated very early in the course
of the infection. If the infection persists or progresses,
then the implant should be removed and the wound
should be allowed to heal over a drain or in severe cases
by secondary intention. Once the infection has totally
cleared, a secondary augmentation and scar revision
should be planned in 6–12 months.
Mondor’s disease is a superficial thrombophlebitis of
the breast that may occur in up to 1–2% of augmentation
patients.58,59 This process usually affects the veins along
the inferior aspect of the breast and occurs most fre-
quently with the inframammary approach. Fortunately,
this is a self-limiting process that usually resolves with
warm compresses over a period of several weeks.
Delayed complications of augmentation
mammaplasty
Periprosthetic capsular contracture
One of the most common delayed complications of
augmentation mammaplasty is the development of a
palpable and deforming periprosthetic capsular con-
tracture. All surgical implants undergo some degree
of encapsulation due to the natural foreign body reac-
tion by the surrounding tissues. Clinically significant
periprosthetic capsular contracture is characterized
by excessive scar formation that leads to firmness,
distortion, and displacement of the breast implant.
Histological examination of these contractures reveals
circumferential linear fibrosis that is especially severe
when formed in response to smooth shell implants. In
1975, Baker proposed a clinical classification system
of capsular contracture after augmentation that is still
commonly used to describe periprosthetic contractures60
(Table 3.2).
While several factors have been identified which
contribute to capsular contracture, the precise etiology
remains unknown. The hypertrophic, circumferential
linear scar probably involves stimulation of myofibro-
blasts that are known to be present within the peri-
prosthetic capsule. Irritation caused by periprosthetic
hematoma, seroma, or silicone gel bleed may incite the
capsular contracture. Other foreign body particles such
as glove powder, lint, or dust may also contribute to the
process.61 Infectious etiologies have also been studied
and are thought to play a role.61 This theory describes a
chronic subclinical infection located immediately adja-
cent to the implant shell within a microscopic biofilm
that is relatively inaccessible to cellular and humoral
immune function. Many strategies have been employed
to prevent periprosthetic capsular contracture. One
strategy has been the creation of a large implant pocket
and maintenance of this oversized pocket with implant
displacement exercises. The use of implants with tex-
tured surfaces has been described above and has been
shown to reduce the rate of capsular contracture in breast
augmentation. Other efforts have focused on minimiz-
ing operative trauma in order to reduce the risk of
seroma or hematoma formation. Seromas, hematomas,
and even blood staining of the periprosthetic tissues
may incite capsular contracture. Any bleeding that does
occur during the dissection needs to be controlled, and
the staining of the tissues with blood should be diluted
with copious irrigation fluid.
Leukotriene receptor antagonists that are used to
treat asthma were studied in capsular contracture but
are recommended to be used cautiously due to their
side effects.62,63 Specifically zafirlukast (Accolate) and
montelukast (Singulair) have been shown to reverse
clinical signs of capsular contracture in patients taking
the medication for asthma.62,63 Treatment of established
capsular contractures usually requires operative inter-
vention. This is discussed more completely in Chapter
4. Open capsulotomy involves scoring the capsule cir-
cumferentially, and anteriorly to adequately release and
expand the soft-tissue envelope. With very thick fibrous
capsules, or with calcified capsules containing silicone
granulomas, it is often necessary to perform either a
partial or complete capsulectomy to correct the defor-
mity. This is often extremely effective in treating
advanced grade IV capsular contractures, especially
when the implant is replaced with a saline-filled or a
Table 3.2  Grades of capsular contracture
Grade I
Capsular contracture of the augmented breast
feels as soft as an unoperated breast.
Grade II
Capsular contracture is minimal. The breast is less
soft than an unoperated breast. The implant can
be palpated but is not visible.
Grade III
Capsular contracture is moderate. The breast is
firmer. The implant can be palpated easily and
may be distorted or visible.
Grade IV
Capsular contracture is severe. The breast is hard,
tender, and painful, with significant distortion
present. The capsule thickness is not directly
proportional to palpable firmness, although
some relationship may exist.

48
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
Secondary procedures
Revisionary breast surgery (secondary or tertiary),
which is often performed for the late complications of
breast augmentation, poses a continual challenge to
plastic surgeons. These procedures are complex, chal-
lenging, and unpredictable. Over the years, we have
been dealing with thinned breast tissues from large
implants that have been placed either in subglandular
or subpectoral space leading to some long-term compli-
cations, such as implant extrusion, gel bleed, rupture
with extravasation of gel, saline implant deflation,
capsular contracture, palpability, rippling, “double
bubble”, “snoopy breast”, symmastia, and implant
malposition.
Historically, our options for revision and improve-
ment have included, replacing saline implants with gel
implants, using capsular flaps to gain additional stabil-
ity and coverage, or performing a site change operation.
None of these procedures have resulted in complete
resolution of the described complaints. The detailed
management of revisionary procedures will be discussed
in Chapter 17.
no-bleed silicone gel-filled implant. Implant site change
surgery has become popular for treating established or
recurrent capsular contracture.64–66 Revisionary surgery
will be discussed in the next chapter in detail.
Implant rupture and deflation
Any defect in the silicone elastomer shell of a saline-
filled breast implant will ultimately result in deflation of
the implant. The saline filling material leaks out of the
implant and is harmlessly absorbed by the surrounding
tissues. Clinical recognition of deflation is usually made
by the patient and virtually always requires surgical
explantation and replacement of the implant. A history
of recent trauma is frequently elicited with deflation,
and true spontaneous failure of the implant shell is rela-
tively rare.
MRI of the breast is considered the state-of-the-art
technique for evaluating breast implant integrity.
Modern fourth- and fifth-generation silicone gel
are substantially more cohesive than the second- and
third-generation gel and less likely to leak into the sur-
rounding tissues, even when the implant shell is
ruptured.
22. Cunningham B. The Mentor Study on Contour Profile Gel Silicone
MemoryGel Breast Implants. Plast Reconstr Surg. 2007;120:33S–39S.
24. Cunningham B, McCue J. Safety and effectiveness of Mentor’s
MemoryGel implants at 6 years. Aesthetic Plast Surg. 2009;33:440–
444. The authors update on the post approval study for Mentor
Corporation. The study shows that Mentor MemoryGel silicone breast
implants represent a safe and effective choice for women seeking breast
augmentation or breast reconstruction following mastectomy.
26. Bengtson BP, Van Natta BW, Murphy DK, et al. Style 410 highly
cohesive silicone breast implant core study results at 3 years. Plast
Reconstr Surg. 2007;120:40S–48S.
41. Spear SL, Murphy DK, Slicton A, Walker PS. Inamed silicone breast
implant core study results at 6 years. Plast Reconstr Surg.
2007;120:8S–16S, discussion 7S–8S. The authors update on the post
approval study for Allergan Corporation. The study demonstrates the
safety and effectiveness of Natrelle (formerly Inamed) silicone-filled breast
implants through 6 years, including a low rupture rate and high
satisfaction rate.
44. Tebbetts JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272. This article describes specific
indications and techniques for a dual-plane approach to breast
augmentation. Indications, operative techniques, results, and
complications for this series of patients are presented. Dual-plane
augmentation mammaplasty adjusts implant and tissue relationships to
ensure adequate soft-tissue coverage while optimizing implant–soft-tissue
dynamics to offer increased benefits and fewer trade-offs compared with a
single pocket location in a wide range of breast types.
52. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in
aesthetic and reconstructive breast surgery using triple antibiotic
breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;117:30–36. The authors show the clinical importance of the use
of triple antibiotic breast irrigation. This study shows the lower incidence
of capsular contracture compared with other published reports, and its
clinical efficacy supports previously published in vitro studies. Application
of triple antibiotic irrigation is recommended for all aesthetic and
reconstructive breast procedures and is cost effective.
54. Magnusson M, Hoglund P, Johansson K, et al. Pentoxifylline and
vitamin E treatment for prevention of radiation-induced side-effects
in women with breast cancer: a phase two, double-blind, placebo-
controlled randomised clinical trial (Ptx-5). Eur J Cancer.
2009;45:2488–2495.
60. Spear SL, Baker JL Jr. Classification of capsular contracture after
prosthetic breast reconstruction. Plast Reconstr Surg. 1995;96:1119–
1123, discussion 1124.
Access the complete reference list online at

48.e1
References
References
1. Shipley RH, O’Donnell JM, Bader KF. Personality characteristics of
women seeking breast augmentation. Comparison to small-busted
and average-busted controls. Plast Reconstr Surg. 1977;60:369–376.
2. Baker JL Jr, Kolin IS, Bartlett ES. Psychosexual dynamics of patients
undergoing mammary augmentation. Plast Reconstr Surg.
1974;53:652–659.
3. American Society of Plastic Surgeons. Procedural statistics – 2015.
<>;
2015 (Accessed 27.01.17).
4. Czerny V. Plastic replacement of the breast with a lipoma. Chir Kong
Verhandl. 1895;2:216.
5. Longacre JJ. Correction of the hypoplastic breast with special
reference to reconstruction of the “nipple type breast” with local
dermo-fat pedicle flaps. Plast Reconstr Surg. 1954;14:431–441.
6. Maxwell GP, Gabriel A. Possible future development of implants
and breast augmentation. Clin Plast Surg. 2009;36:167–172, viii.
7. Maxwell GP, Gabriel A. The evolution of breast implants. Clin Plast
Surg. 2009;36:1–13, v.
8. Regnault P, Baker TJ, Gleason MC, et al. Clinical trial and
evaluation of a proposed new inflatable mammary prosthesis. Plast
Reconstr Surg. 1972;50:220–226.
9. Cronin TD, Brauer RO. Augmentation mammaplasty. Surg Clin
North Am. 1971;51:441–452.
10. Tanne JH. FDA approves silicone breast implants 14 years after
their withdrawal. BMJ. 2006;333:1139.
11. Cronin TD, Greenberg RL. Our experiences with the silastic gel
breast prosthesis. Plast Reconstr Surg. 1970;46:1–7.
12. Thomsen JL, Christensen L, Nielsen M, et al. Histologic changes
and silicone concentrations in human breast tissue surrounding
silicone breast prostheses. Plast Reconstr Surg. 1990;85:38–41.
13. Cohen IK. Impact of the FDA ban on silicone breast implants. J Surg
Oncol. 1994;56:1.
14. Lundberg GD. The breast implant controversy. A clash of ethics and
law. JAMA. 1993;270:2608.
15. Kessler DA, Merkatz RB, Schapiro R. A call for higher standards for
breast implants. JAMA. 1993;270:2607–2608.
16. Handel N, Wellisch D, Silverstein MJ, et al. Knowledge, concern,
and satisfaction among augmentation mammaplasty patients. Ann
Plast Surg. 1993;30:13–20, discussion 20–22.
17. Stombler RE. Breast implants and the FDA: past, present, and
future. Plast Surg Nurs. 1993;13:185–187, 200.
18. Fisher JC. The silicone controversy–when will science prevail? N
Engl J Med. 1992;326:1696–1698.
19. Guidoin R, Rolland C, Fleury D, et al. Physical characterization of
unimplanted gel filled breast implants. Should old standards be
revisited? ASAIO J. 1994;40:943–958.
20. Sitbon E. [Manufacturing of mammary implants: a manufacturing
of high technology]. Ann Chir Plast Esthet. 2005;50:394–407.
21. Spear SL, Parikh PM, Goldstein JA. History of breast implants and
the food and drug administration. Clin Plast Surg. 2009;36:15–21, v.
22. Cunningham B. The Mentor Study on Contour Profile Gel Silicone
MemoryGel Breast Implants. Plast Reconstr Surg. 2007;120:33S–39S.
23. Cunningham B. The Mentor Core Study on Silicone MemoryGel
Breast Implants. Plast Reconstr Surg. 2007;120:19S–29S, discussion
30S–32S.
24. Cunningham B, McCue J. Safety and effectiveness of Mentor’s
MemoryGel implants at 6 years. Aesthetic Plast Surg. 2009;33:440–
444. The authors update on the post approval study for Mentor
Corporation. The study shows that Mentor MemoryGel silicone breast
implants represent a safe and effective choice for women seeking breast
augmentation or breast reconstruction following mastectomy.
25. Spear SL, Heden P. Allergan’s silicone gel breast implants. Expert
Rev Med Devices. 2007;4:699–708.
26. Bengtson BP, Van Natta BW, Murphy DK, et al. Style 410 highly
cohesive silicone breast implant core study results at 3 years. Plast
Reconstr Surg. 2007;120:40S–48S.
27. Maxwell GP, Van Natta BW, Murphy DK, et al. Natrelle style 410
form-stable silicone breast implants: core study results at 6 years.
Aesthet Surg J. 2012;32:709–717.
28. Stevens WG, Harrington J, Alizadeh K, et al. Five-year follow-up
data from the U.S. clinical trial for Sientra’s U.S. Food and Drug
Administration-approved Silimed(R) brand round and shaped
implants with high-strength silicone gel. Plast Reconstr Surg.
2012;130:973–981.
29. Brohim RM, Foresman PA, Hildebrandt PK, Rodeheaver GT. Early
tissue reaction to textured breast implant surfaces. Ann Plast Surg.
1992;28:354–362.
30. Abramo AC, De Oliveira VR, Ledo-Silva MC, De Oliveira EL. How
texture-inducing contraction vectors affect the fibrous capsule
shrinkage around breasts implants? Aesthetic Plast Surg.
2010;34:555–560.
31. Handel N, Jensen JA, Black Q, et al. The fate of breast implants: a
critical analysis of complications and outcomes. Plast Reconstr Surg.
1995;96:1521–1533.
32. Daka JN, Chawla AS. Release of chemicals from polyurethane foam
in the Meme breast implant. Biomater Artif Cells Immobilization
Biotechnol. 1993;21:23–46.
33. Danino AM, Basmacioglu P, Saito S, et al. Comparison of the
capsular response to the Biocell RTV and Mentor 1600 Siltex breast
implant surface texturing: a scanning electron microscopic study.
Plast Reconstr Surg. 2001;108:2047–2052.
34. Barr S, Hill E, Bayat A. Current implant surface technology: an
examination of their nanostructure and their influence on fibroblast
alignment and biocompatibility. Eplasty. 2009;9:e22.
35. Stevens WG, Nahabedian MY, Calobrace MB, et al. Risk factor
analysis for capsular contracture: a 5-year sientra study analysis
using round, smooth, and textured implants for breast
augmentation. Plast Reconstr Surg. 2013;132:1115–1123.
36. Hammond DC, Perry LC, Maxwell GP, Fisher J. Morphologic
analysis of tissue-expander shape using a biomechanical model.
Plast Reconstr Surg. 1993;92:255–259.
37. Brody GS. Silicone technology for the plastic surgeon. Clin Plast
Surg. 1988;15:517–520.
38. Asplund O. Capsular contracture in silicone gel and saline-filled
breast implants after reconstruction. Plast Reconstr Surg.
1984;73:270–275.
39. Burkhardt BR, Dempsey PD, Schnur PL, Tofield JJ. Capsular
contracture: a prospective study of the effect of local antibacterial
agents. Plast Reconstr Surg. 1986;77:919–932.
40. Gylbert L, Asplund O, Jurell G. Capsular contracture after breast
reconstruction with silicone-gel and saline-filled implants: a 6-year
follow-up. Plast Reconstr Surg. 1990;85:373–377.
41. Spear SL, Murphy DK, Slicton A, Walker PS. Inamed silicone breast
implant core study results at 6 years. Plast Reconstr Surg.
2007;120:8S–16S, discussion 7S–8S. The authors update on the post
approval study for Allergan Corporation. The study demonstrates the
safety and effectiveness of Natrelle (formerly Inamed) silicone-filled breast
implants through 6 years, including a low rupture rate and high
satisfaction rate.
42. Brown MH, Shenker R, Silver SA. Cohesive silicone gel breast
implants in aesthetic and reconstructive breast surgery. Plast
Reconstr Surg. 2005;116:768–779, discussion 80–81.
43. Weum S, de Weerd L, Kristiansen B. Form stability of the Style 410
anatomically shaped cohesive silicone gel-filled breast implant in
subglandular breast augmentation evaluated with magnetic
resonance imaging. Plast Reconstr Surg. 2011;127:409–413.
44. Tebbetts JB. Dual plane breast augmentation: optimizing
implant-soft-tissue relationships in a wide range of breast
types. Plast Reconstr Surg. 2001;107:1255–1272. This article
describes specific indications and techniques for a dual-plane
approach to breast augmentation. Indications, operative techniques,
results, and complications for this series of patients are presented.
Dual-plane augmentation mammaplasty adjusts implant and tissue
relationships to ensure adequate soft-tissue coverage while optimizing
implant–soft-tissue dynamics to offer increased benefits and fewer
trade-offs compared with a single pocket location in a wide range
of breast types.

48.e2
SECTION I
CHAPTER 3 • Device considerations in breast augmentation
45. Gabriel A, Fritzsche S, Creasman C, et al. Incidence of breast and
chest wall asymmetries: 4D photography. Aesthet Surg J. 2011;31(5):
506–510.
46. Hunstad JP, Webb LS. Subfascial breast augmentation: a
comprehensive experience. Aesthetic Plast Surg. 2010;34:365–373.
47. Tijerina VN, Saenz RA, Garcia-Guerrero J. Experience of 1000 cases
on subfascial breast augmentation. Aesthetic Plast Surg.
2010;34:16–22.
48. Siclovan HR, Jomah JA. Advantages and outcomes in subfascial
breast augmentation: a two-year review of experience. Aesthetic
Plast Surg. 2008;32:426–431.
49. Parsa FD, Parsa AA, Hsu A. Subfascial periareolar augmentation
mammaplasty. Plast Reconstr Surg. 2006;117:681–682, author reply
2–3.
50. Graf RM, Bernardes A, Rippel R, et al. Subfascial breast implant: a
new procedure. Plast Reconstr Surg. 2003;111:904–908.
51. Gabriel A, Maxwell GP. The evolution of breast implants. Clin Plast
Surg. 2015;42:399–404.
52. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in
aesthetic and reconstructive breast surgery using triple antibiotic
breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;117:30–36. The authors show the clinical importance of the use
of triple antibiotic breast irrigation. This study shows the lower incidence
of capsular contracture compared with other published reports, and its
clinical efficacy supports previously published in vitro studies. Application
of triple antibiotic irrigation is recommended for all aesthetic and
reconstructive breast procedures and is cost effective.
53. Hoehler H. Breast augmentation: the axillary approach. Br J Plast
Surg. 1973;26:373–376.
54. Magnusson M, Hoglund P, Johansson K, et al. Pentoxifylline and
vitamin E treatment for prevention of radiation-induced side-effects
in women with breast cancer: a phase two, double-blind, placebo-
controlled randomised clinical trial (Ptx-5). Eur J Cancer.
2009;45:2488–2495.
55. Mofid MM, Klatsky SA, Singh NK, Nahabedian MY. Nipple-areola
complex sensitivity after primary breast augmentation: a
comparison of periareolar and inframammary incision approaches.
Plast Reconstr Surg. 2006;117:1694–1698.
56. Pfeiffer P, Jorgensen S, Kristiansen TB, et al. Protective effect of
topical antibiotics in breast augmentation. Plast Reconstr Surg.
2009;124:629–634.
57. Williams C, Aston S, Rees TD. The effect of hematoma on the
thickness of pseudosheaths around silicone implants. Plast Reconstr
Surg. 1975;56:194–198.
58. Dudrap E, Milliez PY, Auquit-Auckbur I, Bony-Rerolle S. [Mondor’s
disease and breast plastic surgery]. Ann Chir Plast Esthet.
2010;55:233–237.
59. Viana GA, Okano FM. Superficial thrombophlebitis (Mondor’s
Disease) after breast augmentation surgery. Indian J Plast Surg.
2008;41:219–221.
60. Spear SL, Baker JL Jr. Classification of capsular contracture after
prosthetic breast reconstruction. Plast Reconstr Surg. 1995;96:1119–
1123, discussion 1124.
61. Adams WP Jr. Capsular contracture: what is it? What causes it?
How can it be prevented and managed? Clin Plast Surg.
2009;36:119–126, vii.
62. Gryskiewicz JM. Investigation of accolate and singulair for
treatment of capsular contracture yields safety concerns. Aesthet
Surg J. 2003;23:98–101.
63. Riccioni G, Bucciarelli T, Mancini B, et al. Antileukotriene drugs:
clinical application, effectiveness and safety. Curr Med Chem.
2007;14:1966–1977.
64. Maxwell GP, Tebbetts JB, Hester TR. Site Change in Breast Surgery.
Presented at: American Association of Plastic Surgeons, St. Louis,
MO; 1994.
65. Maxwell GP, Gabriel A. The neopectoral pocket in revisionary
breast surgery. Aesthet Surg J. 2008;28:463–467.
66. Maxwell GP, Birchenough SA, Gabriel A. Efficacy of neopectoral
pocket in revisionary breast surgery. Aesthet Surg J. 2009;29:379–385.
67. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative
care. JAMA. 2001;286:208–216.
68. Teng CM, Kuo SC, Ko FN, et al. Antiplatelet actions of panaxynol
and ginsenosides isolated from ginseng. Biochim Biophys Acta.
1989;990:315–320.
69. Baldwin CA, Anderson LA, Philipson JD. What pharmacists should
know about feverfew. J Pharm Pharmacol. 1987;39:459–465.
70. Heller J, Gabbay JS, Ghadjar K, et al. Top-10 list of herbal and
supplemental medicines used by cosmetic patients: what the plastic
surgeon needs to know. Plast Reconstr Surg. 2006;117:436–445,
discussion 46–47.
71. Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks of
herbal, homeopathic, and dietary supplements: a hidden nightmare
for plastic surgeons? Aesthet Surg J. 2012;32:332–346.

SECTION I • Aesthetic Breast Surgery
4 
Breast augmentation
M. Bradley Calobrace
SYNOPSIS
■ Breast augmentation is one of the most commonly performed
aesthetic procedures in the United States and abroad.
■ Preoperative assessment should determine the appropriate approach
including choice of implant, breast pocket (submuscular, subfascial,
subglandular, subpectoral with dual plane), incision location
(inframammary, periareolar, transaxillary, transumbilical), and the need
to lower the inframammary fold.
■ Implant selection has expanded over the past few years to include
many variables including implant fill (saline or silicone), implant shell
surface (smooth or textured), implant form (round or shaped), implant
dimensions (width, size, projections), and implant cohesiveness
(fourth- or fifth-generation implants) with associated differences in
form stability and implant softness.
■ Inframammary fold positioning is critical to establishing optimal
implant placement in the pocket.
■ Surgical approach, implant choice, and operative technique can impact
the incidence of complications, including implant malposition and
capsular contracture.
Introduction
The primary indication for breast augmentation is
simply inadequate volume of breast tissue, or glandular
hypoplasia. This may occur from either a developmental
or involutional process. Developmental hypoplasia may
be either primary in nature or secondary to other devel-
opmental problems such as thoracic hypoplasia (Poland
syndrome) or other chest wall deformities (pectus
excavatum). Whereas developmental hypoplasia often
involves deficiencies of skin, subcutaneous tissue and
underlying glandular tissue, involutional changes
involve hypoplasia of the glandular breast tissue with
often a relative excess of skin and subcutaneous tissue.
Involutional hypoplasia usually manifests as glandular
ptosis or pseudoptosis which is most associated with
postpartum breast, but can likewise be affected by
breastfeeding, hormonal changes and weight fluctua-
tions. Breast augmentation is likewise performed for
psychological reasons.1 Several studies revealed that
women seeking breast augmentation feel their breasts
are inadequate and can create doubt as to her femininity
and desirability.2–4 Inadequate breast size as compared
to the norm has been associated with low self-esteem,
negative body image and feelings of inadequacy.5
This can negatively impact interpersonal relationships,
sexual fulfillment and quality of life.6
Access the Historical Perspective section and Table 4.1
online at

Preoperative planning
One of the most critical steps in achieving excellence in
breast augmentation is the preoperative evaluation.
The initial consultation should evaluate the patient’s
goals and expectations for the breast augmentation
procedure. Patients have often done a lot of research
about the procedure and the surgeon and may be
seeking multiple consultations prior to making a deci-
sion. The surgeon’s evaluation should be able to estab-
lish the patient as well-informed, stable and possessing
reasonable expectations for the procedure. A thorough
history and physical examination are essential to iden-
tify any risk factors for the procedure. Screening
mammograms, although not mandatory, are usually

49.e1
Historical perspective
Historical perspective
Evolution of breast implants
Saline implants
The inflatable saline prosthesis was introduced by
Arion from France in 1965.7 It was developed to allow
the non-inflated implant to be placed through a small
incision and then be inflated once in the breast pocket.8
In the United States, Rees and associates reported
in 1973 on their use of a similar saline implant known
as the Mammatech prosthesis.9 The implant consisted
of a smooth silastic shell filled with normal saline solu-
tion and sealed with a polytetrafluoroethylene plug.
These saline implants we plagued with significant
deflation rates of 76% at 3 years.10 Shortly thereafter,
the Heyer-Schulte Company introduced their saline
implant (Mentor 1-800) with a significant improvement
in deflation rates, ranging in reports from 0.5% to
15.5%.11–13
The thin implant shell and leaflet-style fill valves of
these early implants contributed to the high deflation
rate. Currently available saline implants manufactured
by Allergan and Mentor have similar characteristics of
a thicker silicone elastomer shell and processing through
new room-temperature vulcanization (RTV).
Saline implants are currently available with a wide
range of profiles and sizes with unique dimensional
characteristics and recommended fill volumes. Under-
filling a saline implant can lead to high deflation rates
due to potential fold fatigue or friction on the implant
shell and is not recommended. Underfilling an implant
can also potentially lead to increased incidence of wrin-
kling or rippling of the implant. Saline implants perform
best when slightly overfilled, as significant overfill may
lead to an abnormal rounded shape, altered dimensions,
firmness and edge scalloping that can be palpable or
visible along the edges of the implant. Lastly, the con-
sistency of the saline implants is that of water and
generally does not create the natural feel of a softer,
more viscous substance that would more mimic the feel
of a breast.
Silicone gel implants
The introduction of the silicone gel implant by Cronin
and Gerow and manufactured by Dow Corning began
the modern era of breast augmentation and over the
past 50 years breast implants have evolved to encom-
pass a wide array of commercially available implants
today.14 Peters originally described three generations of
silicone breast implants which was further refined and
described as five generations by Maxwell and Baker.15,16
The first generation implants (1962–1970) were charac-
terized by a moderately viscous silicone gel surrounded
by a thick, smooth silicone elastomer shell with a seam
along the periphery. This implant was anatomically
(teardrop) shaped with Dacron patches on the posterior
surface. These implants were plagued by relatively high
capsular contracture rates. In an effort to reduce this and
meet the desire from surgeons for a less firm, more
natural-feeling implant, the second generation breast
implants (1970–1982) were developed. These implants
were filled with a thinner silicone gel and surrounded
by a thinner, slightly permeable shell without the Dacron
patches or seams along the edge. The implants were
round and softer creating a more natural feel. These
implant shells proved unreliable with increased rupture
rates and silicone gel diffusion (bleed) through the
implant shell secondary to a thin, permeable shell and
a less viscous silicone gel. The subsequent third genera-
tion (1982–1992) implants were created with a more
viscous gel and a thicker smooth or textured shell, with
a less permeable low-bleed barrier elastomer as an
attempt to reduce gel bleed, implant rupture and cap-
sular contracture.17 These implants are created with a
shell that is multi-layered silicone elastomer and has led
to lower implant rupture rates and almost immeasur-
able gel bleed. The fourth generation implants (1993–
present) are the current standard silicone gel round
implants available in the United States including the
Allergan Natrelle and Mentor MemoryGel implants and
are differentiated from the previous generation of pre-
moratorium implants by refinements in the manufactur-
ing process.
The fifth generation of implants (2012–present) have
the same silicone elastomer and low bleed shells present
in the previous generations, filled with a silicone gel
with greater cohesiveness that has a greater ability to
retains its shape in varying positions. This has allowed
for the creation of an array of round and anatomically
shaped implants that more predictably maintain their
shape and are less affected by the surrounding soft
tissue forces or gravity.
Evolution of shaped implants
Anatomically shaped breast implants were created to
fill the market need for a more natural result than the
full upper pole produced by the round gel implant. The
current fifth generation implants can conceptually be
traced back to the Replicon (Surgitek) implants of the
1980s with an anatomic shape and a textured shell,
giving the breast a “one breast feel” where the implant
is adherent to the breast tissue and is no longer a mobile

49.e2
SECTION I
CHAPTER 4 • Breast augmentation
structure, easily discernible in the underlying breast
mound. The polyurethane shell on these implants was
an attempt to reduce capsular contracture, but was
prone to degrade, resulting in a thin, pliable shell that
was more susceptible to visible folds, rupture, silicone
leakage and late capsular contractures.17–19 In the early
1990s, Tebbetts introduced the concept that both implant
shell and the contents of the shell contribute to the final
shape of the implant.20 The manufacturers could alter
the softness or firmness of the silicone gel and implant
by modifying the degree of cross-linking. The significant
advancement in development provided sufficient cross-
linking and thus stiffness to the implant to allow it to
maintain its shape in different positions and resist the
inherent deforming pressure and forces of the surround-
ing breast tissue. These concepts led to Tebbetts’ aid in
the design of the original Style 410 implant for McGhan/
Inamed in 1993.21,22
Due to the suspension by the Food and Drug Admin-
istration, much of the experience and development of
cohesive shaped breast implants occurred outside the
United States over the next decade. Cohesive gel
implants – referred to as fifth generation – became avail-
able in Canada through a special access program of the
Medical Device Bureau of Health Canada in November
2000 and the Style 410 implant, with more cohesive gel,
began evaluation in the United States under an Investi-
gational Device Exemption Study in February 2001.23,24
Both the CPG and the Sientra HSC+ initiated their IDE
studies within the next year. Beginning in 2012, fifth
generation round and anatomically shaped implants
began receiving approvals from the Food and Drug
Administration and are now commercially available
from all three manufacturers. The current regulatory
approval status of silicone-gel breast implants in the
United States appears in Table 4.1.
Table 4.1  Current approval status of gel breast implants in the United States.
Round implants (2006–2012 FDA approvals)
Shaped implants (2012–2013 FDA approvals)
Allergan Natrelle – November 2006
Sientra HSC+ – March 2012
Mentor MemoryGel – November 2006
Allergan 410 – February 2013
Sientra High Strength Cohesive – March 2012
Mentor MemoryShape – June 2013

50
SECTION I
CHAPTER 4 • Breast augmentation
amount of breast parenchyma present and the level of
ptosis. This is essential in determining the optimal
pocket for implant placement. The elasticity of the skin
should likewise be assessed. Stretching the skin and
noting redundancy as well as evaluation for looseness
of the skin and stretch marks provide important infor-
mation. This can greatly influence the surgical approach
and implant selection.
Measurements
There are important measurements that should be a
part of every evaluation for a breast augmentation (see
Fig. 3.5).
Base diameter
The most important measurement is base diameter. This
provides important information in implant selection, as
each implant has a unique base diameter as well. It is
important to realize that while each patient has a fixed
breast base diameter, the measured (actual) breast diameter,
an equally important determination is the desired (or
ideal) breast diameter when determining implant selec-
tion. This is especially important when the breast is very
narrow and the base width of the breast needs to be
expanded to create an ideal breast. This measurement
can be rather subjective based on the anatomy but is
often the distance from the anterior axillary line to 1 cm
lateral to the midline.
Sternal notch to nipple
The next measurement is the sternal notch to nipple
(SN–N) distance which provides information on the
length of the thorax and the position of the breast on the
chest.
Breast height
It is helpful to measure the breast height to assess upper
pole volume and coverage and to assess symmetry. The
SN–N and breast height measurements are especially
important when selecting whether to use a round
implant or a shaped implant of variable heights.
Nipple to inframammary fold
A key measurement is the distance from the nipple to
the inframammary fold in relaxed position and on
stretch. The distance under stretch provides important
information about the amount of skin available in the
lower pole of the breast. Inadequate skin in the lower
pole may require lowering the fold for appropriate
implant positioning. On the contrary, excessive skin in
the lower pole may be a determinant for pocket
recommended for patients aged 35 and older or even
younger if a significant family history or risk factors
are identified.
In the preoperative assessment, it is important to
understand the goals of the patient and what type of
look she finds appealing. Whereas the look of the breast
is rather subjective and is undoubtedly influenced by
cultural elements as well as personal preference, most
would agree there are certain shared characteristics of
the female breast form that create an ideal aesthetic. The
characteristics including a full, sloping upper pole that
leads to a fuller, gently curving lower pole. The nipple
areolar complex is centralized on the breast positioned
at the point of maximal projection on the breast mound
above the inframammary fold. The breast mound itself
is composed of parenchymal breast tissue lying on the
anterior chest wall surrounded and enveloped with a
soft-tissue covering made up of skin and adipose tissue
(see Fig. 3.1).
A thorough evaluation of the breast form includes a
complete evaluation of the breast and chest wall as well
as taking precise measurements using the nipple areolar
complex and inframammary fold as key landmarks. The
preoperative markings create a roadmap for the planned
procedure (Fig. 4.1). It is imperative to critically evalu-
ate for asymmetries, including the chest wall, inframa-
mmary fold, volume, and nipple areolar complex
position. A thorough exam for any palpable masses or
lymph nodes should also be performed. A more subjec-
tive analysis includes the evaluation of the soft-tissue
coverage including quality of skin and breast tissue,
Fig. 4.1  Preoperative markings in the upright position provide critical landmarks
for the planned procedure.

51
Operative planning
anything other than medical review is a requirement
and should be documented. There are many options
available in breast augmentation and many of the deci-
sions are subjective and based on the desires of the
patient for a particular outcome. It takes clear commu-
nication that is appropriately documented on the desired
shape and size of the breast and the plan to achieve the
result. It is often helpful to make the patient a part of
that process through 4D imaging or trying on implants
with sizers so the selected implant is a mutual decision
between the surgeon and the patient.
Operative planning
Incision length and placement
The decision on incision placement is based on a variety
of variables, including patient and surgeon preferences,
anatomic considerations, implant type and size. The
size of the incision depends on the location, but in
general should be as small as possible and yet large
enough to safely dissect the pocket and place the implant
without distortion or injury to the device. In general, the
length of the incision would be smaller with saline
compared to silicone implants, and longer when placing
more cohesive implants, larger implants and/or tex-
tured implants. Fractures of form-stable cohesive
implants and rupture or distortion of silicone implants
have been associated with attempting to place implants
through incisions inadequate to accommodate the
implant. Additionally, the quality of the scar is often
better if a slightly larger scar is utilized, reducing the
stretch and retraction injury placed on the scar. Incision
length ranges include: 3–4.5 cm for saline implants,
4–6 cm for silicone round implants and 4.5–7 cm for
shaped cohesive silicone implants.
There are four different incision options for breast
augmentation: inframammary, periareolar, transaxillary
and transumbilical. Each incision has distinct advan-
tages and disadvantages that must be discussed with
the patient. After implant selection, the choice of inci-
sion should be based on surgeon comfort with the
technique, patient desire, and the ability to provide
optimal control and visualization to achieve the desired
outcome for the implant selected.
Inframammary incision
The inframammary incision is the most commonly used
due to its direct access and visualization of the pocket
with the least injury to surrounding structures. This
incision can be used to access the subglandular, subfas-
cial or subpectoral space and can be utilized with virtu-
ally any of the implants. The incision should be placed
selection to expand the skin in the lower pole or even
the need for a mastopexy.
Pinch test
The soft-tissue pinch test is useful in assessing the upper
pole of the breast by pinching the tissue between
the examiner’s index finger and thumb. As a general
rule, if the pinch is less than 2 cm, implant placement
should be subpectoral to avoid upper pole wrinkling.
If the tissue pinch thickness is greater than 2 cm,
the subglandular/subfascial plane could also be
considered.
Imaging systems
In addition to manual measurements, 3D and 4D
imaging is now available and can assist in the evalua-
tion process. Some of the systems automatically provide
all the measurements. Likewise, an impressive evalua-
tion of the soft-tissue contributions, breast shape and
size and chest wall are a part of the assessment. These
automated 4D systems are based on biodimensional
principles and are often more accurate in visualizing
small asymmetries in the chest wall and/or breast25 (see
Figs. 3.2–3.4). This evaluation has the added advantage
of allowing the patient to visualize not only her breast
but also the small asymmetries highlighted in the 4D
evaluation. Patients can also visualize simulations of
different breast implants possible for the augmentations,
increasing their understanding and confidence in the
final decision.
Informed consent
An appropriate informed consent requires an evalua-
tion of the emotional state of the patient and the appro-
priateness of the procedure for the desired outcome.
The entire consultation is part of the informed consent:
listening to the patient’s desires, evaluating for surgery,
explaining the procedure and educating on the risk,
benefits and alternatives to the planned approach. The
official consent of the American Society of Plastic Sur-
geons can be helpful. The implant manufacturers also
provide additional supplemental educational materials
and patient handbooks that review all of the informa-
tion included as part of a comprehensive informed
consent. The informed consent must be signed and
witnessed and included as part of the patient’s medical
record. The use of before and after photographs that
fairly represent the procedure and anticipated results
can be helpful. Likewise, photographing the patient is
an essential part of documentation and requires appro-
priate permission and assurance of confidentiality.
Permission to utilize the patient’s photographs for

52
SECTION I
CHAPTER 4 • Breast augmentation
Inframammary fold positioning
Predicting the final position of the inframammary fold
is critical to determining the placement of all breast
incisions, but especially the inframammary incision.
This can be a challenging task as so many variables
contribute to the final position of the fold. The inframa-
mmary fold is formed by the fusion of the anterior and
posterior leaves of the superficial fascia which is inti-
mately associated with the dermis at the lowest aspect
of the inferior pole of the breast.26 Prior to surgery, the
inframammary fold (IMF) is identified and marked in
the sitting position. The true IMF position is actually
determined by performing an IMF expansion test. The
breast is grasped and auto-rotated inferiorly to identify
the inferior extent of the attachments of the inframam-
mary fold (Fig. 4.2). This is the best predictor of where
the fold will naturally sit after breast augmentation. The
amount of lower pole skin required and the ultimate
position of the fold is a function of many factors, includ-
ing the type of implant (saline vs. silicone, round vs.
shaped), size of implant, pocket location and the strength
and stability of the soft tissue of the lower pole. The
distance measured from the nipple to true fold under
maximal stretch assesses the amount of lower pole skin
available to accommodate the selected implant. An
acceptable standard that has been used is an implant
with a base diameter of 11 cm requires 7 cm, a base
diameter of 12 cm requires 8 cm, and a base diameter of
13 cm requires 9 cm.27 A more comprehensive evalua-
tion has been described using tissue-based planning
principles.28 In the High Five System analysis, variables
are analyzed including implant volume, patient’s base
in the location of the planned inframammary fold posi-
tion, which may be at the native fold or potentially
lower if the fold is repositioned.
Periareolar incision
Although used less often in the past few years, this
incision can be very useful for someone wanting to
avoid a scar in the fold of the breast. It is most
inconspicuous when there is a distinct border and a
marked color contrast between the areolar skin and
surrounding breast skin. This incision allows direct
access for adjustments in the inframammary fold posi-
tion and in parenchymal scoring and release often
needed in constricted breast deformity. Disadvantages
of this incision include transection of the ducts colo-
nized potentially with bacteria, visible scarring in front
of breast mound, possibly greater nipple sensitivity
changes and limited exposure of the surgical field.
Patients with smaller areolar complexes may also be
inappropriate due to difficulty in implant placement,
especially with larger, textured or shaped implants, as
injury to the implant can occur while trying to place an
implant through the longer breast tunnel associated
with these incisions.
Transaxillary incision
This approach avoids any scar on the breast mound
with the incision placed deep in the axillary space. The
access allows pocket creation either bluntly or with the
aid of an endoscope. The endoscopic approach is pre-
ferred due to the ability to maintain prospective hemo-
stasis through direct visualization and precise release of
the pectoralis muscle above the inframammary fold.
Saline or silicone implants can be placed through this
incision, either above or below the pectoralis muscle.
The placement of shaped implants, more cohesive
implants and larger implants can be more challenging
and may not be possible in every situation. The use of
an insertion sleeve can be very useful in providing ease
of placement.
Transumbilical incision
This incision is located in the upper portion of the
umbilicus and is very well hidden and remote. A clear
disadvantage is only being able to place saline implants
through this incision, which has made this access inci-
sion less utilized in the past few years with the increased
use of silicone implants in the United States. The dissec-
tion is performed bluntly and no direct visualization is
possible to provide prospective hemostasis. Revisions
are generally not possible through this incision and a
second incision is usually required.
Fig. 4.2  The true fold, the best predictor of where the fold will lie postoperatively,
is assessed by autorotation of the breast inferiorly to identify the inferior extent of
the fascial attachments at the fold.

53
Operative planning
lower the inframammary fold due to less postoperative
stretching of the lower pole.28–38
Pocket position
There continues to be divergent thought as to the optimal
pocket for breast implants. The subglandular/subfascial
pocket is the most natural for the implant with
avoidance of animation deformities seen with submus-
cular implants, enhanced correction of constricted
breast or ptotic breasts, ease of dissection and less post-
operative discomfort for the patient39–42 (Fig. 4.4). The
subfascial placement may have some advantages to
subglandular placement. The implant is placed between
the anterior fascia of the pectoralis major and the muscle
itself which may provide additional support to the
overlying soft-tissue envelope, less distortion of the
breast form and decreasing mobility of the implant in
the pocket (see Fig. 3.6). It has been widely accepted that
an upper pole pinch test of 2 cm is required to place an
implant in the subglandular/subfascial pocket to reduce
the risk of upper pole implant visibility or wrinkling.
Although data is mixed and not completely established
as of yet, there is some emerging evidence that textured
implants may be advantageous in the subglandular/
subfascial pocket to reduce the incidence of capsular
contracture.32,43–45
However, maximizing soft-tissue coverage whenever
possible has been one of the most important guiding
principles for success in breast augmentation. Inade-
quate coverage, often combined with heavy, oversized
implants, leads to soft-tissue parenchymal atrophy, skin
stretching due to the pressure and weight of the implant,
and ultimately wrinkling and palpability of the implants
and associated breast deformities.29,30 The subpectoral
pocket provides the greatest coverage for the implant
and is performed by creating a pocket between the
pectoralis major muscle and the chest wall and the
advantages have included lower capsular contracture
rates, enhanced coverage of the implant minimizing
issues of wrinkling, creation of a more natural, sloping
upper pole and enhanced support for the breast
implant.32,39,43,46,47 Undoubtedly, the issues of wrinkling
and need for enhanced coverage with saline implants
provided the impetus for subpectoral pockets becoming
the preferred pocket by US surgeons.
The challenges with a purely subpectoral implant is
greater animation distortion, the inability to expand the
lower pole of a ptotic breast, and lack of exposure of the
lower pole for parenchymal scoring (such as with a
constricted breast deformity). Thus, the author’s pre-
ferred pocket is the dual plane pocket. In all actuality, a
subpectoral placement where the origin of the muscle is
width, implant base width, anterior pulled skin stretch,
and nipple-to-fold distance under maximal stretch.
Based on the selected implant, a reference chart provides
the desired nipple-to-fold distance, which if longer than
the measured distance, will require IMF lowering. In
determining fold position, the author has found an
alternative method extremely useful. This calculation
takes into consideration implant selections that may fall
outside the limits of appropriate tissue-based planning.
The required distance from nipple to fold is calculated
as a function of implant height and implant projection,
which is useful for both round and shaped implants.
Optimal N-IMF distance
implant projection
implant heig
=
+
12
12
ht
IMF Lowering
Optimal N-IMF distance
measured N-IMF distanc
=
−
e maximum stretch
(
)
If the desired nipple-to-inframammary fold (N–IMF)
distance is equal or less than the measured N–IMF
distance, then the fold does not require lowering. The
distance can be adjusted based upon expectation for
lower pole stretch postoperatively. This observation has
become increasingly important as more textured round
and shaped implants are being used. It is important to
recognize that inframammary fold lowering is less often
required when placing a smooth silicone implant, espe-
cially if higher profile or larger sized implants are used
secondary to lower pole stretch over time29,30 (Fig. 4.3).
However, when placing textured implants, inframam-
mary fold lowering may be required more often com-
pared to smooth implants due less lower pole stretch
and inferior implant descent created by the frictional
component or adherence of the texture in the implant
pocket.31,32 Likewise, shaped implants are not only tex-
tured but also have a greater volume of a more cohesive
gel present in the lower pole of the implant, thus requir-
ing more lower pole skin to accommodate the implant.33–38
Box 4.1 identifies some implant and soft-tissue charac-
teristics that may be associated with greater need to
BOX 4.1  Characteristics associated with less stretching of the lower
pole
Textured implants
Cohesive implants
Shaped implants
Silicone compared to saline implants
Lower profile implants
Smaller implants
Tight, firm breast skin

54
SECTION I
CHAPTER 4 • Breast augmentation
and the lower portion of the implant is subglandular
(Fig. 4.6). The greater the level of dual plane, the greater
portion of the lower pole covering the implant is sub-
glandular (see Fig. 3.10).
Pocket control
No matter which pocket is selected, it is helpful during
the marking process to identify as accurately as
divided above the fold constitutes a level 1 dual plane,
as the lower portion below the division technically
places the implant in the subglandular plane (Fig. 4.5).
The dual plane, initially described by Tebbetts, maxi-
mizes coverage and support of the breast implant while
allowing for exposure and expansion of the lower
pole when indicated.47 In the dual plane, the pectoralis
muscle covers over the superior portion of the implant
A
B
C
D
Fig. 4.3  Preoperative (A–C) and postoperative (D–F) views of a 45-year-old with inframammary fold lowering and placement of classic anatomic shaped textured 400 cc
implants.
E
F

55
Operative planning
possible the pocket size necessary to accommodate the
selected implant. This will provide a pocket that main-
tains the implant in a controlled position and mini-
mizes the risk of postoperative implant malposition. In
breast augmentation with round implants, the accurate
placement of the inframammary fold and control of
the medial and lateral extent of the pockets provide
ideal implant positioning to achieve the desired
A
B
C
D
Fig. 4.4  Preoperative (A,C,E) and postoperative (B,D,F) views of a 31-year-old Poland syndrome patient with textured round implants. (A,C,E) 425 cc high profile; (B,D,F)
320 cc moderate profile in subfascial position.
E
F
cleavage and minimize lateral migration of the
implant.31 When using a shaped implant, a controlled
pocket is even more essential to minimize the risk of
implant rotation postoperatively.33,36,38 This requires not
only controlling the pocket similar to a round implant,
but additionally limiting the dissection of the superior
pocket to snuggly accommodate the height of the
shaped implant.

56
SECTION I
CHAPTER 4 • Breast augmentation
Fig. 4.5  Preoperative (A,C,E) and postoperative (B,D,F) views of a 43-year-old with smooth round 235 cc moderate profile implants in the submuscular (dual plane 1)
position.
A
B
C
D
E
F
Implant selection
Filler material
In the United States there are currently two broad catego-
ries of implants based on the filler material: saline and
silicone. The ultimate decision between using saline and
silicone implant is ultimately the patient’s after a thor-
ough discussion of the differences, risk and benefits of
each of these implants. Saline implants can be placed
subpectoral with excellent aesthetic results. The incisions
to place saline implants are smaller and differential fill of
saline implants allows easy correction of minor breast or
chest wall asymmetries. In thinner patients or when
implants are placed subglandular, wrinkling becomes
palpable in almost all cases and visible in some. It is
generally agreed that silicone implants convey a much
more natural, softer feel as compared to saline implants.
Within the silicone category, there are different options

57
Operative planning
Fig. 4.6  Preoperative (A,C,E) and postoperative (B,D,F) views of a 44-year-old with textured round 355 cc moderate profile implants placed in the submuscular (dual
plane 2) position to allow for adequate redraping of the pseudoptotic breast tissue over the implant.
A
B
C
D
E
F
based on the cohesiveness of the silicone gel within the
implant. Silicone is a mixture of semi-inorganic morpoly-
meric molecules composed of varying length chains of
polydimethyl siloxane monomers. The physical proper-
ties of silicone are quite variable depending on the
average polymer chain length and the degree of cross-
linking between the polymer chains. Silicone gels can be
produced with varying viscosities by varying the length
of the polymer chain or the amount of cross-linking. The
Allergan Natrelle implant and Mentor MemoryGel
implants represent the fourth generation implants uti-
lized since the early 1990s and FDA-approved for general
use in 2006. The silicone gel in these implants is cohesive
in nature with a cross-linked silicone gel, yet has a very
soft feel. More recently, the term “cohesive” and “form-
stable” have been used interchangeably to describe a
newer generation of implants that are even more cohe-
sive in nature with greater cross-linking, allowing the

58
SECTION I
CHAPTER 4 • Breast augmentation
There is no doubt a patient’s request for a particular
breast size or shape greatly determines the dimensions
of the breast implant utilized. In addition to physical
assessment and a discussion with the patient, additional
maneuvers may prove helpful including trying on some
type of implant sizer or the use of a 4D imaging system
to demonstrate for the patient the outcomes anticipated
based on the implant selected.
Implant surface texture
The decision on whether to use a smooth or textured
implant is really only applicable to round implants, as all
anatomic shaped implants require texture to maintain
their orientation and prevent rotation. In the past few
decades when only saline and fourth generation round
silicone implants were available in the United States,
smooth surface devices were used in the vast majority of
cases. For round devices, texture may impart some
reduction in the capsular contracture rate and maintain
its position within the breast pocket, especially with
associated chest wall asymmetries or abnormalities.
There is emerging evidence the texturing reduces the
capsular contracture rates when placed subglandular/
subfascial.32,43-45 When placed submuscular, the smooth
and textured devices have similar capsular contracture
rates, although some recent data reveals a possible small
protective effect of texture even in the submuscular
position.32,43 Recently, with greater choices of implants
including shaped devices from all three manufacturers
in the US, the use of texture devices has increased signifi-
cantly. The textured surface creates a frictional interface
between the implant surface and the capsule that tends
to help the implant remain properly oriented.
Each manufacturer has a proprietary type of surface
texture. The Mentor texture is created by pressing a thin
sheet of polyurethane foam into a tacky thin sheet of
silicone, imprinting the shell with a Siltex texture. This
is the least aggressive texture and actual tissue ingrowth
does not occur. The Mentor MemoryShape implant
texture is more aggressive than the round MemoryGel
implant. The Allergan 410 implant is referred to as
BioCell. It is manufactured by adding salt crystals to the
still tacky external surface of the implant shell and then
covering the device with an additional thin layer of sili-
cone. During the final phase, the thin external silicone
layer is scrubbed away and the salt granules dissolve,
leaving behind an open pore network of individual cells
creating an aggressive type texture. This texture can
actually create tissue ingrowth from the surrounding
capsule. Sientra HSC and HSC+ implants have a TRUE
Texture, which is created by a proprietary process and
does not involve imprinting, soap-and-scrub technique
or salt-loss, sugar-loss processing.
implants to maintain their shape in different positions
and to resist the inherent deforming pressure and forces
of the surrounding breast tissue. The greater cohesive-
ness of the silicone gel used in the implants has allowed
not only more form-stable round implants but also the
creation of implants with anatomic shape. The gel of the
fifth generation implants is more cohesive and includes
the Sientra HSC and Allergan’s Natrelle Inspira cohesive
round implants and the Sientra HSC+, Mentor Memo-
ryShape and Allergan 410 cohesive silicone gel shaped
implants. As form stability increases, so does the firm-
ness of the implant. The Mentor MemoryShape implants
are more form-stable than their Sientra HSC counterpart
but less than Allergan’s Style 410. Therefore, the Mentor
MemoryShape would be considered softer than the
Allergan 410 but firmer than the Sientra HSC. It is this
balance between form stability and implant softness that
characterizes each implant, and these attributes will
ultimately contribute to implant performance and patient
satisfaction.
Implant size
The selection of implant size is based both on the goals
of the patient and the surgeon’s assessment. Many
approaches have been described including the biodi-
mensional approach or the BodyLogic approach to
implant selection. More elaborate systems such as the
High-Five, as previously mentioned, can be used as
well. In general, critical assessments in determining size
include the dimensions of the breast, the compliance or
stretch of the soft-tissue envelope and the desired
volume for the resultant augmentation. As mentioned
previously, the width of the breast is related to the width
of the chest wall. It is critical to select an implant width
that respects this width in order to maintain the normal
landmarks such as the anterior axillary line and the
appropriate cleavage and intermammary distance (see
Fig. 3.11). Not respecting these landmarks may lead to
an unnatural and deformed appearance. Size of implant
is not only the width, but also the height and projection.
In round implants, the width and height are the same,
but in shaped implants they are sometimes different.
The projection can vary within any one breast implant
width and provide less or more volume while respect-
ing the width dimension. The projection is determined
in part by the compliance and potential laxity in the
breast envelope, but also by the patient’s desired look.
A lower profile implant would provide less volume and
a more natural look and is more appropriate when the
breast envelope is tight. A higher projecting implant is
used when breast soft-tissue laxity requires projection
and volume to fill out the envelope and in patient’s
desire a more rounded, augmented look.