2008-07-28Breast augmentation is surgery to increase the volume of the female breast by using breast implants. It is a cosmetic procedure done to resolve the dissatisfaction that some women feel with small breasts, either because their breasts never developed to a desired size or because their breasts lost volume after pregnancy, weight loss, or with aging. For these individuals, breast augmentation can provide a more flattering, better proportioned figure, expanded clothing options, and feelings of greater confidence and self-esteem.
At
the same time, a woman choosing to have breast augmentation is assuming
responsibility for dealing with a number of issues that arise with the
use of breast implants. This article outlines the factors to consider
before surgery, describes the techniques and implants that are
available, reviews the complications associated with surgery, explains
the issues associated with the presence of an implant in the body, and suggests the steps someone considering this surgery should take.
The history of breast augmentation
The first report of an effort to increase the volume of the female breast surgically was in 1895 but it was not until 1962, with the development of the sealed silicone gel breast implant, that breast augmentation became widely accepted. By 1990, when reports about a possible association with rheumatic disorders came to light, it was estimated that over 1.2 million American women had implants in place. Concerned about health risks, the US Food and Drug Administration (FDA) restricted the use of implants filled with silicone gel in April 1992. Numerous studies over the next 14 years allayed concerns about serious health risks and provided important information about the incidence of problems and complications with the use of implants. In late 2006, silicone gel breast implants received FDA approval and again became available for use. Throughout the entire period of time, saline-filled silicone-shell breast implants remained available.
Statistics
gathered by the American Society of Plastic Surgeons show that breast
augmentation is the most common cosmetic surgical procedure done in the
US. (1) In
2007, 347,524 patients had breast augmentation, a 64% increase compared
with year 2000, and a striking 868% increase compared with 1992, when
the breast implant concerns were publicized widely. The statistics also show that women having breast augmentation are distributed over a range of ages:
- 31% - age 20-29
- 35% - age 30-39
- 26% - age 40-54
There
has been interest in breast augmentation for over 40 years and the
number of individuals seeking augmentation increases to some extent each
year. This is thought to be due to widespread awareness about breast
augmentation due to information readily available in the electronic and
print media. The challenge is to be sure that any
individual considering this surgery has knowledge of the modern science
about silicone implants and the risks and benefits of the surgery.
What to consider before breast augmentation
In addition to being a surgical procedure with operative and anesthetic risks, breast augmentation involves the use of an implantable medical device. Devices can fail and there are long-term considerations that arise with the presence of a foreign material in the body. Discussion of these points is a key element of the consultation with the plastic surgeon before surgery. (2) Several major factors to consider include:
- If an individual later decides to remove breast implants, the breasts do not revert to their appearance before surgery. The tissue is stretched when an implant is placed under it and may appear flat and droopy when the implant is removed.
- The presence of implants affects the way mammograms are done, since additional views are needed during routine screening mammography to visualize all of the breast tissue. Implants also may lessen the effectiveness of mammograms by making them more difficult to interpret in some cases. Women with a strong family history of breast cancer or a personal history of breast abnormalities must consider whether implants could be an impediment to cancer surveillance.
- Persons with health conditions that impair wound healing or immunologic diseases that diminish the ability to combat infection should be cautious about obtaining an implanted material.
- Individuals who are emotionally vulnerable and find it difficult to handle set-backs should consider that breast augmentation carries the burden of dealing with an implant that is not a lifetime device. The potential for complications over the long term is a psychological burden some may not wish to assume.- Breast augmentation is cosmetic surgery and its costs are not covered by health insurance. Significantly, later costs associated with breast implants such as medical care, additional operations, and special studies to check for implant integrity may not be covered by health insurance.
- Statistics from the American Society of Plastic Surgeons show the average physician fee in 2007 for breast augmentation was $3,816. The cost of implants is in addition to the surgical charges, and gel implants are more expensive than saline implants.
Analysis of breast size and shape
Breast shape. The shape of the breast is determined largely by the skin envelope by which it is covered. As the weight of the breast increases with maturity, the skin stretches and the breast develops a normal slope with less fullness above and more fullness in the lower half of the breast. This is accentuated in individuals with thin skin or skin that has poor elasticity. With little support for the weight of the breast, ptosis or drooping develops as the breast and its skin envelope fall lower on the body. The quality of skin is affected by many factors, including heredity, aging, hormonal changes, weight gain, and pregnancy.Surgical planning. For every individual there are a variety of features that have an impact on the surgical goal - a fuller breast with a natural appearance and pleasing shape. The wishes of the patient are most important but these have to be put in the context of her anatomy, including height, weight, shape of the rib cage, position of the breasts, differences between the two breasts, presence of any ptosis, and tightness of the skin. Dimensions of the breast like width, height, and the amount the breasts protrude into the cleavage and sideways from the body should match the individual’s body build. The tightness of the skin is critical. A patient with very tight skin cannot accommodate as much increase in volume as can someone with more skin. On the other hand, a patient with exceptionally thin, inelastic skin will develop ptosis or drooping when large amounts of weight and volume are introduced into the breast. In situations where a patient already has ptosis before augmentation of the breast, this will need to be corrected before the breast volume is increased in order to avoid worsening the degree of drooping. Surgery done to correct ptosis is called mastopexy, a procedure that removes excess skin and uplifts the breast mound and the nipple and areola. A mastopexy may be done at the same time as breast augmentation, but the technique involves quite a bit more scarring and longer surgery.
Surgical techniques
The basic steps of breast augmentation start with an incision made in the skin and underlying tissue. A pocket is created for a breast implant and the implant is placed and positioned. The pocket and incisions are closed surgically and dressings are used. Within this general description are a large number of technical variations. (3)
Incisions. Three incisions are used commonly for breast augmentation and each has advantages and drawbacks. Choosing one involves analyzing which gives the surgeon the best control for a specific patient’s anatomical needs, and which injures the least amount of normal tissue. The type and size of implant also affects the incision, particularly with regard to its length. Saline implants can be folded up and inserted empty through quite a small incision since they can be unfolded and filled once they are in the pocket. In contrast, silicone gel implants are pre-filled and require a larger skin incision to get them into the body. Thus, the size of a saline implant is immaterial to incision size, but the larger a gel implant the larger the incision needed. The inframammary incision is one located in the crease under the breast. It provides excellent access for creation of the pocket and has the advantage of avoiding surgery within the breast tissue itself. The disadvantage is that it leaves a scar in the crease which may be noticeable in the smaller breast.The periareolar incision is a semicircular one around the edge of the nipple and areola. It tends to heal with little visible scarring because the areola camouflages the scar, but has the disadvantage that it may produce changes in the sensation of the nipple area.The axillary incision is located in the armpit so there are no scars on the breast area itself. With this incision it is more difficult to create the pocket since it is further away from the incision and some operative maneuvers are more difficult.The transumbilical approach, also called TUBA (transumbilical breast augmentation), uses an incision in the navel to introduce a tube through which a rolled-up empty saline implant is placed in a pocket under the breast and then filled with saline. This approach is not recommended because of possible damage to the implant during the process of insertion.
Implants. All modern breast implants, regardless of filling material, have an outer shell or envelope constructed of silicone elastomer. Silicone is rubber and is used in numerous medical devices including heart valves, drains, catheters, and other implants such as chin, hand, and testicular implants. The implants come in many sizes and a variety of shapes such as round, oval, or contoured for more directed projection in one area of the breast. The contoured implants sometimes are called anatomic implants, a term which refers to their design with tapering on the top half and more fullness on the bottom half which mimics the natural shape of the more mature breast.
· Silicone gel-filled implants. These implants contain silicone gel which is polymerized to a consistency very similar to that of breast tissue and as a result they weigh, feel, and move like breast tissue. Gel implants that are currently available have a thicker, more viscous gel than did previous generations of these devices. Called cohesive gel, the material tends to stay in place even if the shell of the implant is damaged. Gel implants are prefilled and sealed and cannot be adjusted in size in the operating room.
· Saline-filled implants. These silicone rubber shells are filled in the operating room by the surgeon with sterile saltwater, called saline. Should the implant leak, the saline which is used routinely as IV or intravenous fluid is absorbed harmlessly by the body. Advantages
of saline implants are the safety factor of the filling material, some
flexibility adjusting size by varying the amount of fluid put in the
implant, and smaller incisions since the implants are inserted while
empty. The primary disadvantage is a
higher incidence of visible rippling or wrinkling of the implant under
the skin, particularly in thin patients.
· Textured implants. The surface of implants can be smooth or textured. The
texturing of the silicone elastomer on the surface of the shell was
once thought to decrease the chances of hardened scarring around the
implants. It may, in fact, contribute to lower rates of implant rupture since the textured shell is thicker. The texturing also tends to stabilize the implant is one position in the pocket, a desirable effect in some situations.
Location of the implant pocket. The pocket into which the breast implant will be placed can be in one of two positions relative to the breast tissue and the pectoralis major muscle fascia which lies deep to the breast. (4)
- Subglandular placement is where the pocket is made directly behind the breast tissue on top of the muscular fascia. This lends more ability to control the shape of the breast and is associated with a more rapid postoperative recovery. Disadvantages include a greater chance of seeing or feeling the edge of the implant through the skin.
- Submuscular placement is where the pocket is made underneath the chest wall muscle. The contour of the breast may be smoother because the edges of the implant are blunted by the muscle, there is less chance of developing hardened scar around the implant, nipple sensation is protected, and mammogram interpretation may be more accurate when the breast tissue is lifted up and away from the implant by the muscle. Disadvantages include more postoperative discomfort and longer recovery, movement of the implant when the muscle is flexed, and less ability to fill the upper breast centrally because the muscle tends to smooth the shape in this area.
Postoperative care. After
surgery, it is useful to wear selected garments to stabilize the
position of the implant. A small dressing is placed over the incision
and a bra worn for support and comfort can be adjusted to help mold the
shape of the breast. An elastic wrap may be used on the
upper part of the breast to keep the implant low in the pocket or to
maintain the orientation of a contoured anatomic implant until healing is completed.
Complications with breast augmentation
When considering potential problems that can develop with breast augmentation, it is helpful to distinguish between operative complications and implant concerns. The operative complications are those that can occur with any surgery and include pain, excessive blood loss, blood collection in the treated area (hematoma), fluid collection in the treated area (seroma), wound infection, decreased sensation of the skin, and scarring. These events are not commonplace. Outcome studies have shown that bleeding or hematoma occurs in 1-3% of cases, wound infections in 1-2% of cases, and some degree of diminished sensation to the nipple in about 15% of cases, depending on which incisions are used and whether the implant pocket is developed under the breast or under the muscle below it. Scarring occurs with every incision and generally is inconspicuous; however, unsightly scars that are wide, thick, or darker or lighter in color develop in a small proportion of patients regardless of which incision is used.
More
numerous and more frequent than these complications associated with
surgery are problems that arise over the weeks, months, or years after
surgery due to the presence of an implanted device. The most common among these are:
- Capsular contracture. After placement of an implant, the human body forms an envelope of scar or fibrous tissue around the implant. This is called a capsule and serves to “wall off” the implant from the tissue around it. In some individuals, for reasons not understood, the capsule becomes thicker or tighter so that the implant no longer feels soft and as pliant as breast tissue. Although the implant itself is unchanged, the encapsulating fibrous tissue makes the breast feel firm or even hard. If the degree of capsular contracture is great, there can be pain, distortion, and palpability or displacement of the implant. Capsular contracture occurs in about 15% of patients, (5) and there is no means to predict who will develop it or to take steps to prevent it. Treatment involves removing the fibrous capsule surgically and replacing the implant but this often results in recurrence of the capsular contracture. (6) The only permanent correction is removal of the implant entirely, a procedure called explantation.
- Implant deflation. Saline filled implants can deflate when the saline solution leaks out of the implant either through the valve or through the implant shell. Statistics from studies of deflation rates show that this occurs in about 7% of cases within the first five years after surgery. The causes are thought to be damage from handling at the time of surgery, pressure from capsular contracture, compression of the implant due to trauma, and other reasons that remain unknown. Deflation is readily obvious as the size of the breast diminishes over a day or two; treatment requires surgery to remove and replace the deflated implant.
- Implant rupture. (7) Silicone gel implants can rupture when the gel material leaks through the implant shell. Statistics on the frequency of this suggest that it occurs at a rate similar to the deflation of saline implants. However, there is an important difference in how the rupture is detected. (8) When a gel implant ruptures, the breast volume will not change since the gel remains in the tissue and in many cases, the rupture remains undiagnosed, or a silent rupture. In other patients, the breast shape may change, fullness or a bulge may develop at the rupture site, or there may be the onset of discomfort or pain. It is recommended that a ruptured gel implant be removed so that inflammation or irritation from the presence of the silicone gel does not develop at some later point in time. In light of this, it is recommended also that gel implants be studied by MRI, magnetic resonance imaging, at intervals of 3-5 years so that silent ruptures can be detected and treated. MRI is the most accurate method for checking implant integrity and is the standard test for this purpose. (9) This periodic surveillance of gel implants is costly since charges are high for an MRI and the cost of the study is not covered by medical health insurance.
- Displacement. Implants may shift after placement, producing a breast mound that is too high, too low, or too close to the side of the body. Implant malposition occurs in 8-9% of patients. Such shifting may be due to scarring or capsular contracture, but if it results in a difference between the two breasts, and if it is severe enough, another operation to correct this may be necessary.
Areas where implant safety has been established
Two
areas of extensive study have been the questions of whether breast
implants are associated with breast cancer, and whether the silicone
material in breast implants is associated with connective tissue
disease.
No
study has ever suggested that the presence of a breast implant is a
cause of breast cancer. The chief question has been whether the presence
of an implant could interfere with the detection of breast cancer by
screening mammograms. Standard mammograms in a woman with breast
implants show only about 75% of the breast tissue since the remainder is
obscured by the implant. To deal with this, Eklund displacement views
are used to increase the amount of tissue that can be seen. The
technique consists of pushing the implant back toward the chest and
wall and compressing portions of the breast tissue to increase the
amount of tissue that can be successfully imaged. Given this, it is
recommended that women with breast implants have mammograms at
facilities familiar with the displacement technique; the schedule for
routine mammography is otherwise the same as for women without implants. Studies
have shown no significant difference between women with and without
implants who do develop breast cancer in terms of the size or stage of
the tumor when it is diagnosed, which suggests that the presence of the
implant is not responsible for delayed detection or a worse prognosis. (10)
A
series from Los Angeles of 3182 women followed for 18.7 years after
breast augmentation showed no increased risk, no delay in diagnosis, and
no worse prognosis for those patients compared with a comparable group
of women without implants. (11)
Concern
about the association of breast implants with the development of
autoimmune or connective tissue diseases, such as lupus, scleroderma, or
rheumatoid arthritis arose because of cases reported in the literature
in the early 1980s. Since then an increasing number of epidemiologic
analyses have failed to support this association. (12) (13) A
committee of the Institute of Medicine of the National Academies of
Science reviewed over 2000 peer-reviewed studies and 1200 data sets and
concluded in 1999 that there was no definitive evidence linking breast
implants to cancer, immunologic diseases, or neurological diseases and
that women with breast implants were no more likely to develop these
disorders than were those in the rest of the population. (14)
Steps potential patients should take
For an individual considering breast enlargement there are more issues to be considered than with most surgical procedures. It is critically important for a patient to have a comprehensive consultation with a plastic surgeon to become familiar with all of the short and long term implications of this surgery. It is equally important to see how these factors apply to each individual’s situation. Which type of implant is best for a given body build? Is there breast drooping? Is there a family history of breast cancer? Is the likelihood of additional surgery over the years acceptable? Are the costs of the required long-term follow-up as well as the original surgery clear?
As can be seen from the information above, success with breast enlargement rests on the good judgment of both the patient and the plastic surgeon. This comes from exchange of information, familiarity with a variety of techniques, selection of the right operation and implant for the right patient, surgery done with trusted anesthesiologists and staff in a safe environment, and a plan for postoperative check-ups over the years to follow.
Surgical planning starts with finding a competent and skillful doctor to begin discussing the issues associated with breast augmentation. One place to start is in the ranks of trained, Board-certified surgeons, credentialed at an accredited medical facility. Resources are available to help with this, and the following Web sites can provide further information and the names of surgeons who have met professional criteria, including requirements for ongoing medical education and interval reexamination for maintenance of certification.
Plastic surgeon referral service 1-888-4-PLASTIC (1-888-475-2784)
For further information about breast implants:
FDA Breast Implant Consumer Handbook.
FDA Guidance for industry and FDA staff: saline, silicone gel, and alternative breast implants. November 17, 2006. http://www.fda.gov/cdrh/ode/guidance/1239.html
(1) American Society of Plastic Surgeons. National Clearinghouse of Plastic Surgery Statistics: 2007 Report of the 2006 Statistics. www.plasticsurgery.org
(2) Wood SF, Spear SL: What do women need to know and when do they need to know it? Plast Reconstr Surg 120 (Suppl 1):135S, 2007.
(3) Hidalgo DA: Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Reconstr Surg 105:2202, 2000.
(4)Tebbetts JB: Dual plane breast augmentation: optimizing implant-soft tissue relationships in a wide range of breast types. Plast Reconstr Surg 107:1255, 2001.
(5) Spear SL, Murphy DK, Slicton A, et al: Inamed silicone breast implant core study results at 6 years. Plast Reconstr Surg 120 (Suppl 1): 8S, 2007.
(6) Young VL: Guidelines and indications for breast implant capsulectomy. Plast Reconstr Surg 102:884, 1998.
(7) Young VL, Watson ME: Breast implant research. Where we have been, where we are, where we need to go. Clin Plast Surg 28(3):451, 2001.
(8) O’Toole M, Caskey CI: Imaging spectrum of breast implant complications: mammography, ultrasound, and magnetic resonance imaging. Semin Ultrasound CT MR 21:351, 2000.
(9) Gorczyca DP, Gorczyca SM, Gorczyca KL: The diagnosis of silicone breast implant rupture. Plast Reconstr Surg 120 (Suppl.1):49S, 2007.
(10) Hoshaw SJ, Klein PJ, Clark BD, et al: Breast implants and cancer: causation, delayed detection, and survival. Plast Reconstr Surg 107:1393, 2001.
(11) Deapen D, Hamilton A, Bernstein L, Brody GS: Breast cancer stage at diagnosis and survival among patients with prior breast implants. Plast Reconstr Surg 105:535, 2000.
(12) Nyren O, Yin Li, Josefsson S, et al: Risk of connective tissue disease and related disorders among women with breast implants: a nation-wide retrospective cohort study in Sweden. BMJ 316:417, 1998.
(13) Jensen B, Bliddal H, Kjoller K, et al: Rheumatic manifestations in Danish women with silicone breast implants. Clin Rheumatol 20:345, 2001.
(14) Marwick C: Are they real? IOM report on breast implant problems. JAMA 282:314, 28 Jul 1999.
