Augmentation Mammoplasty


What is it?
The cosmetic surgery which corrects small breasts is called
Augmentation Mammoplasty. Women typically seek breast enlargement to improve their self image and to look better both in & out of clothing.

What causes it?
Lack or loss of breast volume could be due to underdevelopment of breasts, weight loss, post pregnancy or breast feeding.

How is it done?
Breast enlargement is achieved with the help of a pair of implants inserted underneath the breasts. This is a daycare procedure and does not require any hospitalization in most of the cases.


Implant Selection:
Size: Size is determined by the woman’s desire and the surgical possibilities. The size of the pocket in which the implant is placed is determined by the size of the breast and chest wall. The implant must fit comfortably into the pocket. An oversized implant is not stuffed into a small pocket and a small implant is not placed into a large pocket. The implant must fit the breast. This will normally create a breast in keeping with the patient’s built and chest wall size. Women who request breast size larger than average will require exceptionally large pockets fashioned under the muscle with subsequent insertion of an oversized implant. The result may not be very attractive.

Type of Implants:
Basically there are two kind of implant available for breast augmentation.

  • Silicone gel Implants.
  • Saline filled Implants.


Silicone gel implants
Until recently most physicians used silicone gel implants, which are made of a silicone gel encased in a bag made of a silicone elastomer. At a molecular level the bag is distinguished from the gel by the amount of cross-linked molecules. The bag has more of these molecules giving it a rubber like texture. The purpose of the bag is to prevent the silicone gel from coming into contact with the breast tissue. This kind of Implant gives a very natural feel to the augmented breasts.

Saline filled implants
Saline implants are currently the most popular alternative. A saline implant is made of a salt and water solution encased in a bag made of silicone elastomer. These implants are not as popular because they do not look or feel as natural as the silicone gel implants. The saline can also leak through the silastic bag but is not implicated in the controversy because the salt water is simply absorbed into the body. The only concern with the leak is that the implant may decrease in size over time.

Implant Placement
The implant may be placed under the breast tissue (subglandular augmentation mammoplasty) or under the muscle (submuscular augmentation mammoplasty). The Submuscular technique involves the insertion of an implant into a pocket created under the muscle over which the breast sits and has been the preferred technique for a number of years. The submuscular technique had been more popular in the past because the breasts look and feel more natural, have natural cleavage and the incidence of subsequent breast hardening is dramatically reduced as compared to the subglandular approach with the use of smooth surfaced implants

The submuscular implant however, has drawbacks as well. There tends to be more discomfort immediately after the surgery. On contraction of the chest wall muscle (pectoralis major), the implant underneath the muscle is squeezed flat and pushed sideways. Some women find this unattractive. Submuscular implants affect the performance of such athletes as competitive swimmers and professional weight trainers, who depend on the pectoralis major muscle. Some muscular placement also gives unnatural feeling while swimming as the breasts float separately from the implant.

More recently the use of textured surface implants as reduced the chances of contracture formation even with subglandular placement of implant. So this technique has again come in popular demand as the subglandular approach gives better feel of the augmented breasts.

 

Procedure:
The incision for breast enlargement may be made in the inframammary fold under the breast where it attaches to the chest wall, around the nipple (known medically as peri-areolar), from the outer edge of the armpit (the transaxillary approach) or directly across the nipple areola. The most common incision is a cut 4 centimeters (1⅟₂ inches) in length along the inframammary fold. This makes it easy to create the implant pocket under the muscle, does not disturb the breast tissue too much, and the resulting scar is inconspicuous. The transumbilical technique places the incision in the umbilicus or belly button. The pocket for the implant is created through an endoscope and the silicone bag is out in place. The saline solution is pumped into the bag to achieve the desired size and shape.

Once the implant is in place the incision is usually closed with absorbable sutures and skin tapes. It is then covered with a light dressing, and a soft elastic bra is placed over the breasts.

Augmentation of both breasts takes approximately one hour. The patient returns home in the evening of the day of surgery and should be accompanied by an attendant (driving is not allowed on the day of surgery). Some cases are kept overnight in the hospital, for closer post operative monitoring, and discharged the following day.

Post operative pain:
Some discomfort may be experienced over the breast and the front of the armpit for approximately 3or 4 days. This discomfort gradually subsides. By the seventh day most discomfort disappears, although occasional shooting pains may be felt in the breast area. This might occur for up to 6 months following surgery but the frequency gradually decreases as the breasts heal.

Potential Problems
All the surgery has potential complications. The degree of risk must be weighed with the desired outcome. A breast augmentation can cause the following problems.

◆ Breast Hematoma:

When blood collects in the implant pocket it is called a hematoma. One or both breasts swell and marked pain and tightness is felt as well. Any suspicion of a hematoma, even if small, should be investigated by the surgeon. If a hematoma is present, the pocket of the breast is reopened and the blood is drained. As drainage occurs the breast becomes soft again. If a hematoma remains untreated, a capsular contracture that hardens the breast will almost invariably occur.

◆ Capsular Contracture:

When a layer of fibrous tissue surrounds or encapsulates the implant it is called capsular contracture. Occasionally, excess scar tissue develops around the implant resulting in a hard, often tender breast. This may progress to the point where breast asymmetry occurs, necessitating a second operation through the same incision to remove the fibrous tissue. With the advent of submuscular augmentation, the incidence of capsular contracture has markedly decreased. Approximately 1 in 20 women (5%) will develop a firm breast capsule. The exact cause of breast capsular contracture is unknown.

With submuscular breast enlargements, most breasts that are soft at 6 weeks remain that way, although a delayed fibrous contracture may develop in the odd case. This is most likely due to an unrecognized hematoma in one breast causing an increased amount of scarring around one of the implants. To re-establish breast symmetry, surgical correction is necessary.

 

◆ Decreased Breast sensation :

It is common to notice a change or decrease in breast sensation for the first 3 to 6 weeks following surgery. Usually, normal sensation returns. Approximately 1% of women, however, will complain a permanent change in nipple sensation. This is usually caused by damage to the nerves of the nipple, which could be due to surgical injury or compression by the impact or scar tissue.

◆ Infection:

This is such a rare complication of breast surgery that most surgeon do not place their patient on pre-or post operative antibiotics. It is possible that a low grade infection around the implant is responsible for capsular contractures, but this has not been scientifically confirmed.

 

FAQs:

◆ How much big will the breast be?

Most women increase one or two breast sizes; that is from a 34A to a 34B or C or from a 36A to a 36B or C. A larger breast may be made if so desired.

◆ How soon after surgery may activity be resumed?

Normal activity is possible soon after a breast augmentation provided it does not cause discomfort and pain.

Strenuous activities should be avoided. Patients who do not heed this warning experience much more discomfort and run the risk of developing a hematoma in the implant pocket. A gradual buildup to a full range of activities, such as aerobics, jogging, and swimming, may take place over a 6 week period.

Women who lift weights should avoid pectoral curls or other exercises using the pectoral muscles, as this may tear the scar tissue which forms around the pocket after the incision heals. Vigorous stress on these muscles may cause of the muscles to tear, resulting in capsular contractures.

 

A car may be driven the day following surgery, although a standard shift is often uncomfortable to use. There is no restriction on flying.

◆ Is breast-feeding still possible?

Both submuscular and subglandular breast implants are behind the breast tissue, which means they are out of the way of the breast’s most important function, that of nurturing a baby. The breast responds to pregnancy induced hormones and enlarges and produces milk. With the increased volume and stretching of the breast during pregnancy, some loss of breast posture may occur, just as it does in the breast which is not augmented.

◆ How long the implant remain in the body?

The implant is medically inert and remains intact for longer than human tissue. The breasts continue to age, with a gradual loss of tone. The scar tissue around the implant, in fact, may actually act as an internal bra, providing some support to the breast. These days the recommendation from the manufacturers is to change the implant every 10 years.

◆ What can be done about hard and unattractive implants?

The only treatment now a days is open capsulotomy. Here the implant is removed through the incision of the original surgery. The scar tissue that has enclosed or encapsulated the implant is opened and partially removed. The implant is then reinserted.

Closed capsulotomy , which is non-surgical method is an outdated procedure these day as the implant rupture rate was unacceptably high.

 

◆ Do breast implants cause Cancer?

Currently there is no scientific evidence to suggest that the incidence of cancer increased with the introduction of implants into the breasts.

◆ Will it still be possible to detect cancer after an augmentation?

Breast augmentation does not increase or decrease the incidence of breast cancer. In the case of subglandular implant, some breast tissue atrophy and thinning occurs from compression of the implant on the breast substance. This makes detection of masses or cancer on standard mammography techniques must be used. With submuscular implants, there is a minimal amount of thinning of the breast tissue. Therefore, concern over cancer detection using standard mammography is less of a problem. Another advantage of submuscular augmentation is that a breast biopsy may be performed without disturbing the implant is often damaged during a biopsy due to its more superficial location.

◆ Will an augmentation rid the breast of stretch marks?

Stretch marks cannot be eliminated by enlarging the breast, although they often appear less noticeable because the stretch marks are flattened over the larger breast mound.

◆ What are the alternatives to surgery?

The only alternative is to wear a padded bra. Exercise will not increase the breast size itself. The muscle beneath the breast will enlarge with certain types of exercises which, in effect, increases breast projection but not breast size. Any other external techniques to increase the breast size as is advertised do not offer any effective solution and are highly misleading.

 

  • What is the controversy associated with Silicone Gel Implants ?

The phenomenon of silicone gel bleed is being the subject of studies which has caused lots of concern amongst the users as well as the plastic surgeons. This phenomenon is the result of microscopic leakage from the implant surface. This leaves a slight film of gel on the outer surface of the implant known as a silicone bleed. In the newer generation of implants, the amount of silicone bleed has been significantly reduced by increasing the thickness of the bag. There are some question, however, as to whether the bag itself also sheds silicone into the body over time as it gradually deteriorates. Nothing has been proven for or against this phenomenon and the amount of damage it can cause to the body.

It has been suggested that the introduction of silicone into the body may play a role in human adjuvant disease (HAD), which is implicated in such conditions as rheumatoid arthritis, systemic lupus erythematosus, dermatomyosities, polymyositis, and perhaps even chronic fatigue syndrome. At present a definitive causal relationship has not been established and the current data would suggest that there is no relationship. However, as with all statistics, the data can be interpreted to either support or refute the claims that silicone contributes to HAD and hence the controversy.

What we do know for sure is that the silicone bag definitely become week with time and based on various studies the manufacturers are now recommending the replacement of these implants every 10 years.

 

<<BACK