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Breast Augmentation, Types, Complications

Breast augmentation mammaplasty plastic surgery to increase the size of the female breast, or sometimes to uplift pendulous breasts. It can be done for purely cosmetic purposes, as when a woman wants larger breasts, or following mastectomy to replace surgically removed tissue.

Reconstructive mammaplasty breast reconstruction after mastectomy, done as an alternative to breast forms and specially designed brassieres to achieve a more normal appearance of the breast. If this procedure is chosen, it is usually considered to be just one stage in the total plan of treatment for breast cancer. It has both a psychologic and physiologic impact on the patient. Criteria used to determine whether reconstructive surgery is appropriate post mastectomy include the amount of tissue remaining after mastectomy, e.g., pectoral muscles, skin, and nipple; the probability of recurrent metastatic disease; appearance and size of the unoperated breast; and size and angle of the mastectomy scar. Adjuvant cancer therapy with radiation does not necessarily preclude additional plastic breast surgery.

Breast augmentation sometimes referred to as a “breast aug” or “boob job” by patients, involves using breast implants or fat transfer to increase the size of your breasts. This procedure can also restore breast volume lost after weight reduction or pregnancy, achieve a more rounded breast shape or improve natural breast size asymmetry. Breast augmentation is also referred to as augmentation mammoplasty. When fat from another part of the patient’s body is used to create the improved breast volume, the procedure is referred to as fat transfer breast augmentation.

Baker classification of capsular firmness in augmented breasts

Grade I	No palpable capsule	The augmented breast feels as soft as an unoperated one.
Grade II	Minimal firmness	The breast is less soft and the implant can be palpated, but is not visible.
Grade III	Moderate firmness	The breast is harder, the implant can be palpated easily, and it (or distortion from it) can be seen.
Grade IV	Severe contracture	The breast is hard, tender, painful and cold. Distortion is often marked.

Anatomy of Breast Augmentation

The roughly circular body of the female breast rests on a bed that extends transversely from the lateral border of the sternum to the midaxillary line and vertically from the 2^nd through 6^th ribs. Two thirds of the bed of the breast are formed by the pectoral fascia overlying the pectoralis major, the remaining by the fascia covering the serratus anterior. Between the breast and the pectoral fascia is a loose connective tissue plane or potential space called the retro mammary space (bursa). This plane, containing a small amount of fat, allows the breast some degree of movement on the pectoral fascia. A small part of the mammary gland may extend along the inferolateral edge of the pectoralis major toward the axilla (armpit), forming an axillary process or tail (of Spence).

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The arterial supply of the breast derives from the

Medial mammary branches of perforating branches and anterior intercostal branches of the internal thoracic artery, originating from the subclavian artery.
Lateral thoracic and thoracoacromial arteries, branches of the axillary artery.
Posterior intercostal arteries, branches of the thoracic aorta in the 2^nd, 3^rd, and 4^th intercostal spaces.

The venous drainage of the breast is mainly to the axillary vein, but there is some drainage to the internal thoracic vein

Nerves of the Breast

The nerves of the breast derive from anterior and lateral cutaneous branches of the 4th to 6th intercostal nerves. The anterior primary rami of T1 to T11 are called intercostal nerves because they run within the intercostal spaces. Rami communicantes connect each anterior ramus to a sympathetic trunk. The branches of the intercostal nerves pass through the deep fascia covering the pectoralis major to reach the skin, including the breast in the subcutaneous tissue overlying this muscle. The branches of the intercostal nerves thus convey sensory fibres to the skin of the breast and sympathetic fibres to the blood vessels in the breasts and smooth muscle in the overlying skin and nipple.

Indication for Breast Augmentation

Hypomastia
Tubular breast
Breast reconstruction
Cosmetic correction

Preoperative investigations

Complete haemogram, blood sugar, urea and creatinine
Bleeding profile
Chest X-ray
Mammogram

Assessment

A thorough physical assessment should be done, prior to the operation. The bone and muscle structural foundation of each breast must be assessed. Note the shape of the thorax. Also note whether the patient is “long” or “short” chested. Key measurements include suprasternal notch to nipple distance, nipple to inframammary fold distance, base width or diameter, and breast height. Characterize the elasticity of the skin by noting evidence of poor compliance such as stretch marks or thin nonelastic dermis.

It is also important to characterize the breast parenchyma itself. The amount, quality, and distribution of the parenchyma may alter surgical techniques

The transaxillary incision can be done either bluntly or with the aid of the endoscope. This approach avoids any scarring on the breast mound. It can be used with both saline and gel filled implants in either a sub pectoral or sub glandular pocket. The problems with this approach are difficulty with parenchymal alterations and probable need for a second incision in the breast mound for secondary correction surgeries. Placing the implant in proper position may be difficult.

Transumblical breast augmentation has the great advantage of a single, well hidden, remote incision. Only saline implants can be used in this approach. Obtaining haemostasis is a problem from this remote access port.

Surgical Procedures

An augmentation mammoplasty for emplacing breast implants has three therapeutic purposes:

Primary reconstruction – to replace breast tissues damaged by trauma (blunt, penetrating, blast), disease (breast cancer), and failed anatomic development (tuberous breast deformity).
Revision and reconstruction – to revise (correct) the outcome of a previous breast reconstruction surgery.
Primary augmentation – to aesthetically augment the size, form, and feel of the breasts.

The operating room time of post–mastectomy breast reconstruction, and of breast augmentation surgery is determined by the emplacement procedure employed, the type of incisional technique, the breast implant (type and materials), and the pectoral locale of the implant pocket.^[rx]

Incision Types

The emplacement of a breast implant device is performed with five types of surgical incisions:^[rx]

Inframammary – an incision made below the breast, in the infra-mammary fold (IMF), which affords maximal access for precise dissection and emplacement of the breast implant devices. It is the preferred surgical technique for emplacing silicone-gel implants, because of the longer incisions required; yet, IMF implantation can produce thicker, slightly more visible surgical scars.
Periareolar – an incision made along the areolar periphery (border), which provides an optimal approach when adjustments to the IMF position are required, or when a mastopexy(breast lift) is included to the primary mammoplasty procedure. In the periareolar emplacement method, the incision is around the medial-half (inferior half) of the areola’s circumference. Silicone-gel implants can be difficult to emplace with this incision, because of the short, five-centimetre length (~ 5.0 cm.) of the required access-incision. Aesthetically, because the scars are at the areola’s border, they usually are less visible than the IMF-incision scars of women with light-pigment areolae. Furthermore, periareolar implantation produces a greater incidence of capsular contracture, severs the milk ducts and the nerves to the nipple, thus causes the most post-operative functional problems, e.g. impeded breast feeding.
Transaxillary – an incision made to the axilla (armpit), from which the dissection tunnels medially, thus allows emplacing the implants without producing visible scars upon the breast proper; yet is likelier to produce inferior asymmetry of the implant-device position. Therefore, surgical revision of transaxillary emplaced breast implants usually requires either an IMF incision or a periareolar incision. Trans axillary emplacement can be performed bluntly or with an endoscope (illuminated video microcamera).
Transumbilical – a trans-umbilical breast augmentation (TUBA) is a less common implant-device insertion technique wherein the incision is at the navel, and the dissection tunnels superiorly. This surgical approach enables emplacing the breast implants without producing visible scars upon the breast; but it makes appropriate dissection and device-emplacement more technically difficult. A TUBA procedure is performed bluntly – without the endoscope’s visual assistance – and is not appropriate for emplacing (pre-filled) silicone-gel implants, because of the great potential for damaging the elastomer silicone shell of the breast-implant device during its manual insertion through the short – two-centimetre (~2.0 cm.) – incision at the navel, and because pre-filled silicone-gel implants are incompressible, and cannot be inserted through so small an incision.^[rx]
Transabdominal – as in the TUBA procedure, in the transabdominoplasty breast augmentation (TABA), the breast implants are tunneled superiorly from the abdominal incision into bluntly dissected implant pockets, while the patient simultaneously undergoes an abdominoplasty.^[rx]

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Implant pocket placement

The four surgical approaches to emplacing a breast implant to the implant pocket are described in anatomical relation to the pectoralis major muscle.

Subglandular – The breast implant is emplaced to the retromammary space, between the breast tissue (the mammary gland) and the pectoralis major muscle (major muscle of the chest), which most approximates the plane of normal breast tissue, and affords the most aesthetic results. Yet, in women with thin pectoral soft-tissue, the subglandular position is likelier to show the ripples and wrinkles of the underlying implant. Moreover, the capsular contracture incidence rate is slightly greater with subglandular implantation.
Subfascial – The breast implant is emplaced beneath the fascia of the pectoralis major muscle; the subfascial position is a variant of the subglandular position for the breast implant.^[rx] The technical advantages of the subfascial implant-pocket technique are debated; proponent surgeons report that the layer of fascial tissue provides greater implant coverage and better sustains its position.^[rx]
Subpectoral (dual plane) – The breast implant is emplaced beneath the pectoralis major muscle, after the surgeon releases the inferior muscular attachments, with or without partial dissection of the subglandular plane. Resultantly, the upper pole of the implant is partially beneath the pectoralis major muscle, while the lower pole of the implant is in the subglandular plane. This implantation technique achieves maximal coverage of the upper pole of the implant, while allowing the expansion of the implant’s lower pole; however, “animation deformity”, the movement of the implants in the subpectoral plane can be excessive for some patients.^[rx]
Submuscular – The breast implant is emplaced beneath the pectoralis major muscle, without releasing the inferior origin of the muscle proper. Total muscular coverage of the implant can be achieved by releasing the lateral muscles of the chest wall – either the serratus muscle or the pectoralis minor muscle, or both – and suturing it, or them, to the pectoralis major muscle. In breast reconstruction surgery, the submuscular implantation approach effects maximal coverage of the breast implants.

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Post-Surgical Recovery

The surgical scars of a breast augmentation mammoplasty heal at 6-weeks post-operative, and fade within several months, according to the skin type of the woman. Depending upon the daily physical activity the woman might require, the augmentation mammoplasty patient usually resumes her normal life activities at about 1-week post-operative. The woman who underwent submuscular implantation (beneath the pectoralis major muscles) usually has a longer post–operative convalescence, and experiences more pain, because of the healing of the deep-tissue cuts into the chest muscles for the breast augmenation. The patient usually does not exercise or engage in strenuous physical activities for about six weeks. Moreover, during the initial convalescence, the patient is encouraged to regularly exercise (flex and move) her arms to alleviate pain and discomfort; and, as required, analgesic medication catheters for alleviating pain.^[rx]^[rx]

Indications of Breast Augmentation

Increase fullness and projection of your breasts
Improve balance of breast and hip contours
Enhance your self-image and self-confidence
The post-operative aspect of a right-breast cancer mastectomy; the woman is a candidate for a primary breast reconstruction with a breast implant.

Contraindications of Breast Augmentation

Contraindications include the following

Severe lung or cardiac disease
Collagen vascular disease
Obesity
Older patient (more than age 65)
Smoker and unwilling to quit Surgery
Unstable emotional history
Prior abdominal or thoracic surgery that has interrupted blood supply to the potential flaps
Prior radiation therapy
Advanced breast cancer

Complications

Early postoperative complications include

Infection
Scarring
Asymmetry
Hematoma
Seroma
Breast pain
Poor cosmetic outcome
Nipple/breast sensation changes
Implant malposition or displacement
Implant deflation or leak
Capsular contracture which is tightening of the tissue capsule around the implant