Breast Augmentation (eBook)

Foreword 5
Preface 6
Contents 7
List of Contributors 13
Anatomy, Benign Breast Disease, Malignant Breast Disease, Mammograms 26
Embryology and Anatomy of the Breast 27
Introduction 27
Embryogenesis 27
Congenital Anomalies 28
Anatomy 31
Histology 45
Conclusions 47
References 47
Nerves, Ligaments, and Vessels of the Chest and Breast 49
Introduction 49
Nerves, Ligaments, Vessels 49
References 50
Anthropomorphic Measurement of the Breast 51
Introduction 51
Shape 51
Volume 51
Position 52
Pathological Morphology of the Breast 53
Ptosis and Projection 53
Protocol History 53
Breast Envelope Quality 53
Protocol Method 56
Definitions 56
Accuracy 57
Clinical Application 60
References 66
Anatomy and Clinical Significance of the Pectoral Fascia 69
Introduction 69
Results 69
Technique 69
Discussion 71
Conclusions 73
References 73
The Inframammary Crease 74
Introduction 74
Anatomy 74
Reconstruction of the Inframammary Fold 76
Discussion 77
References 78
Breast Asymmetries: A Working Formulation 79
Introduction Materials and Methods 79
Results 81
Discussion 81
Conclusions 82
References 83
Benign Disorders of the Breast 84
Introduction 84
Benign Disorders 84
History 84
Physical Examination 84
Mammography 84
Discussion 85
References 85
Malignant Breast Diseases 86
Introduction 86
Breast Augmentation 86
Cancer 86
Genetic Testing Chromosome 87
Breast Cancer Prevention Options 88
Discussion 88
Conclusions 88
Mammograms in Cosmetic Breast Surgery 89
Introduction 89
Preoperative Mammograms 89
Postoperative Mammograms Following Cosmetic 89
Breast Surgery 89
Cosmetic Surgeries 90
Discussion 91
References 91
Preoperative Consultation 93
Initial Consultation 94
Introduction 94
Subjective Reasons for Breast Augmentation 94
Physical Examination 94
History 94
Informed Consent Discussion 95
Implants 95
Method for Determining Bra Size and Predicting Postaugmentation Breast Size 96
Introduction Technique 96
Discussion 98
Results 98
Conclusions 102
References 102
Breast Assessment and Implant Selection Using the TTM Aesthetic Breast Chart 103
Introduction 103
Preoperative Assessment Using the TTM Chart 103
Implant Selection 118
Soft Tissue Cover Tension and Capsule Formation 124
Conclusions 125
References 125
The Golden Ratios of the Breast 127
Introduction Method 127
Results 128
Discussion 128
Choosing the Right Prosthesis 129
Conclusions 130
References 133
Body Image and Other Psychological Issues in Breast Augmentation 135
Introduction 135
Preoperative Psychosocial Status of Breast Augmentation Candidates 135
Changes in Psychosocial Status Following Breast Augmentation 136
Cosmetic Breast Augmentation and Suicide 137
Preoperative Psychological Assessment of Breast Augmentation Patients 138
References 140
Conclusions 140
Body Dysmorphic Disorder 144
Introduction 144
Definition 144
Symptoms 144
Consequences of BDD 144
Discussion 145
Associated Disorders 145
Treatment Conclusions 145
References 145
Use of Decision and Management Algorithms in a Breast Augmentation Practice 147
Introduction Incorporating the Algorithms in Patient Education Use of Decision and Management Algorithms 147
Practical Clinical Use of Algorithms in the Office 147
Implant Size Change 170
Alternatives for Managing Possible Periprosthetic Space Infection 171
Alternatives for Managing Capsular Contracture Grades 3 and 4 171
Alternatives for Managing Stretch Deformities and Implant Malposition 171
Management of Shell Disruption or Leaking Silicone Gel Implant 173
Alternatives for Managing Undefined Symptom Complexes 174
Conclusions 174
References 176
Implants 178
Silicone Versus Saline Implants 179
Introduction 179
Implant Characteristics 180
Patient Characteristics 186
Conclusions 188
References 189
Choice of Prosthesis Surface: Myth or Necessity? 191
Introduction 191
History 191
Variety of Available Prostheses 192
Definitions 192
Effect of Smooth-Textured Prostheses on Augmentation Mammaplasty Surgery 193
Effect of Texturization and Smoothness on Augmentation Mammaplasty 193
Effect of Textured Prostheses on Augmentation Mammaplasty 194
Adherence of Textured Prostheses (Advantage of Adhesion to Surrounding Tissue) 195
Effect of Texture on Capsule Formation 195
Conclusions 195
References 195
Enhanced Projection: Adjustable Gel Implants 198
Introduction 198
Saline Implants 198
Silicone Implants 198
Double-Lumen Adjustable Implants 199
Enhanced Projection: Adjustable Gel Implant 199
Betadine and Breast Implants 203
Introduction Discussion 203
Study on Betadine 203
Conclusions 203
References 203
Mechanical Analysis of Explanted Silicone Breast Implants 204
Introduction 204
Materials and Methods 204
Results 205
Discussion 205
References 207
Cohesive Gel Silicone Implants 208
Introduction Contraindications 208
Anesthesia 208
Patient Selection 208
Technique 208
Preoperative Routine Examination 208
Postoperative Care 209
Results 210
Complications 211
Conclusions 211
Surgical Approaches 214
Principles of Breast Augmentation Surgery 215
Introduction 215
Principles 215
Controversies of Certain Methods 216
Postoperative Manipulation of the Implants 216
Conclusions 216
Intraoperative Assessment of Breast Prosthesis Volume Using a Set of Graduated Expanders 217
Introduction 217
Technique 217
References 220
Discussion 220
Conclusions 220
Breast Augmentation: Intraareolar Approach 221
Introduction 221
Technique 221
Preoperative 221
Postoperative Care 222
Discussion 223
Breast Augmentation Using the Periareolar Approach 225
Introduction 225
Technique 225
Results 226
Discussion 227
References 229
Conclusions 229
Inframammary Approach to Subglandular Breast Augmentation 231
Introduction Breast Implants and Subglandular 231
Breast Augmentation 231
Patient Evaluation 235
Patient Examination 236
Operative Technique 236
Postoperative Care 238
References 239
Complications 239
Breast Augmentation: Axillary Approach 241
Introduction 241
Initial Consultation 241
Indications for Breast Augmentation 242
Augmentation, Mastopexy, or Both? 242
Preoperative Work-Up 242
Technique 242
Mastopexy and Augmentation Performed Postoperative Care Simultaneously: 246
Results 246
Avoidance of Common Complications 247
Discussion 249
Conclusions 250
References 250
Hydrodissection Axillary Breast Augmentation 251
Introduction 251
Surgical Technique 251
Preoperative 251
Postoperative Care 252
Complications 255
Conclusions 255
Nipple or Areolar Reduction with Simultaneous Breast Augmentation 256
Introduction 256
Surgical Technique 256
Results 257
Complications 257
Discussion 259
References 259
Conclusions 259
Classification of Breast Ptosis 260
Introduction 260
Lalardrie–Jouglard Classification 260
Regnault Classification of Breast Ptosis 261
Lewis Classification 261
Brink Classification 261
Brink Procedural Specifics for Forms of Breast Ptosis 261
LaTrenta and Hoffman Classification 263
Conclusions 264
De la Torre and Vasconez Classification 264
References 264
Breast Augmentation with Mastopexy 265
Introduction 265
Definition of Ptosis 265
Types of Mastopexy 267
Estimating Volume 268
Technique 269
Case Examples 277
Conclusions 281
References 282
Crescent Mastopexy with Augmentation 284
33.1 284
Introduction 284
33.2 284
Indications 284
33.3 285
Technique 285
33.4 286
Case Results 286
33.5 286
Complications 286
33.6 287
Discussion 287
References 288
33.7 288
Conclusions 288
Breast Augmentation with Periareolar Mastopexy 289
Introduction 289
History 289
Indications 289
Augmentation Alone 289
Preoperative Planning 289
Staging 289
Operative Technique 291
Risks and Complications 293
Conclusions 293
References 296
Mastopexy/Reduction and Augmentation Without Vertical Scar 297
Introduction Consultation 297
Surgical Procedure 297
Postoperative Care 300
Complications 300
Conclusions 300
Classification of the Tuberous Breast 302
Introduction Grolleau Classification 302
Von Heimburg Classification 302
Discussion 302
References 305
The Incidence of Tuberous Breast Deformity in Asymmetric and Symmetric Mammaplasty Patients 306
Introduction 306
Technique 306
Discussion 308
Results 308
References 311
Conclusions 311
Aesthetic Reconstruction of the Tuberous Breast Deformity 312
Introduction 312
History 312
Anatomy and Embryology 313
Techniques 315
Complications Discussion 322
References 323
Periareolar Technique for Correction and Augmentation of the Tuberous Breast 325
Introduction Anatomy 325
Surgical Treatment 326
Results and Complications 328
Discussion 328
Conclusions 330
References 332
The Effect of Breast Parenchymal Maldistribution on Augmentation Mammoplasty Decisions 333
References 335
Management of Anterior Chest Wall Deformity in Breast Augmentation 336
Introduction 336
Clinical Evaluation 336
Types of Deformities 336
Radiographic Evaluation 336
Manubriosternal Prominence, Pectus Carinatum, and Prominent Costosternal Junction 337
Pectus Excavatum 338
Poland’s Syndrome 339
Sunken Chest (Anterior Thoracic Hypoplasia) 340
Scoliosis 341
Customized Chest Wall Implant: Moulage Preparation 342
Conclusions 345
Discussion 345
References 345
Poland’s Syndrome 347
Introduction 347
Etiology 347
Clinical Presentations 348
Treatment 351
References 358
Breast Augmentation in the Transsexual 361
Introduction 361
Discussion 361
Technique 361
Conclusions 362
Anesthetic Drip System to Reduce Pain in Cosmetic Surgery 364
Introduction Technique 364
Discussion 367
References 368
Position of Implant 369
Submammary Versus Subpectoral Implant 370
Introduction 370
Submammary Pocket 370
Markings 370
Subpectoral Pocket 372
Discussion 372
Conclusions 378
References 379
Treatment of the Submammary Fold in Breast Implantation 381
Introduction 381
Anatomy 381
Factors Distorting the Inframammary Fold 381
Surgical Maneuvers Treatment of the Submammary Fold 382
Nipple–Inframammary Fold Relationships 383
Implant Size and Submammary Fold Problems 385
References 386
Conclusions 386
Subfascial Prepectoral Implant Using the Inframammary Approach 387
Introduction 387
Incision Site 388
Pocket Dissection 392
Discussion 394
References 397
Subfascial Transaxillary Breast Augmentation 399
Introduction Technique 399
Postoperative Care 401
Results 401
Discussion 402
Conclusions 405
References 406
Modified Subfascial Breast Augmentation 407
Introduction 407
Technique 407
Results 408
Complications 408
Discussion 408
Conclusions 410
References 411
Submuscular Fascial Dual-Plane Breast Augmentation 412
Introduction 412
Retromuscular Glandular Dual-Plane 413
Breast Augmentation 413
Retromuscular Fascial Dual-Plane 415
Breast Augmentation 415
Technique 416
Clinical Cases 417
Conclusions 422
References 425
“Reverse” Dual-Plane Mammaplasty 426
Introduction 426
Technique 426
Postoperative Care 428
Discussion 429
Results 429
Conclusions 430
References 431
Breast Augmentation with Autologous Tissue 432
History of Breast Augmentation with Autologous Fat 433
Introduction Recent History with Liposuctioned Fat 433
Historical Contributions 433
Discussion 435
References 436
Breast Augmentation with Autologous Fat 438
Introduction 438
Case Reports 438
Technique 438
References 444
Discussion 444
Fat Transfer with Platelet-Rich Plasma for Breast Augmentation 445
Introduction 445
General Biology of Wound and Graft Healing with PRP 447
Autologous Fat Graft Healing Model 448
Technique 449
Results and Complications 454
Discussion 456
Conclusions 458
References 460
Fat Transfer and Implant Breast Augmentation 464
Introduction 464
Clinical Case 464
Technique 464
Discussion 467
References 467
Breast Augmentation with the Brava® External Tissue Expander 469
Introduction 469
History 469
Discussion 472
Conclusions 475
References 476
Autogenous Augmentation Mammaplasty with Microsurgical Tissue Transfer 477
Introduction History 477
Technique 478
Results and Complications 478
Discussion 479
Conclusions 481
References 482
Complications 484
Complications of Breast Augmentation 485
Introduction 485
Capsular Contracture 485
Implant Displacement 488
Implant Rotation 488
Implant Deflation or Rupture 489
Implant Rippling 489
Seroma 490
Hematoma 490
Infection 490
Hypertrophic Scarring 491
Sensory Changes to Nipple–Areolar Complex 491
References 492
Mondor’s Disease 492
Steroids and Other Complications 492
Pneumothorax 492
Less Common Complications of Breast Augmentation 494
Introduction Areolar Retraction 494
Axillary Banding 495
Autoinflation, Spontaneous 495
Capsule Contracture 496
Double Bubble 496
Calcifications 496
Chronic Pain 496
Elevated Platinum Levels 498
Fibrotic Retraction 498
Galactorrhea 498
Idiosyncratic Allergic Reaction 498
Improper Implant Placement 499
Late Bleeding After Breast Augmentation 499
Malposition of the Inframammary Scar 499
Lactation Problems 499
Methicillin-Resistant 500
Infection 500
Community-Acquired Methicillin-Resistant (CA-MRSA) 500
Migration of Implant 502
Myospasm of Pectoralis Major Muscle 502
Neurologic Injury 503
Necrosis 503
Pneumothorax 506
Periareolar Scar Indentation 506
Synmastia 507
Rippling 507
Serous Fluid Drainage 507
Thromboembolism 507
Synmastia (Symmastia) 510
Toxic Shock Syndrome 510
Capsular Contracture Following Augmentation Mammaplasty: Etiology and Pathogenesis 514
Introduction 514
Histological Characteristics of Capsules Surrounding Mammary Prostheses 514
The Enigma of Myofibroblasts 517
Etiology of Capsular Contracture 518
Miscellaneous Factors 524
References 527
Management of Established Capsular Contracture 527
Complications Related to the Implant 530
Introduction 530
History 530
Techniques 530
Rupture 531
Radiolucency 532
Saline Implants 532
Silicone 532
Polyurethane-Coated Implants 533
Titanium-Coated Implants 533
Soybean Implants (Triglyceride-Filled) Conclusions 533
PVP Implants 533
References 534
Surrounding Mammary Prostheses Within the Breast 535
Introduction 535
Mammographic Imaging 536
Ultrasound 540
Magnetic Resonance Imaging 545
Expected Outcomes of Imaging Implants 547
Conclusions 549
References 549
Treatment of Capsule Contracture with Endoscopic CO Laser 551
Introduction 551
Technique 552
Discussion 553
Results 553
Conclusions 554
References 555
Hammock Capsulorrhaphy 556
Introduction 556
Physiopathology 556
Etiology 556
Anatomic Features 557
Technique 557
Results 557
Conclusions 557
Breast Implant Malposition: Prevention and Correction 560
Introduction 560
Preoperative Analysis 560
Operative Technique 561
Postoperative Management 562
Correction of Implant Malposition 562
Conclusions 563
References 568
Aesthetic Outcome of Breast Implant Removal 570
Introduction Reasons for Implant Removal 570
Implant Removal and Timing of Any Reconstructive Options 575
Technique and Results 581
Conclusions 584
References 586
Inframammary Fold Elevation and External Synmastia Repair: Morgan–Metcalf Method 588
Introduction 588
Technique 588
Synmastia 588
References 591
Intracapsular Allogenic Dermal Grafts for Periprosthetic Breast Implant Problems 592
Introduction 592
Technique 592
Complications 593
Results 593
Discussion 593
Conclusions 593
References 595
Submammary Flap for Correction of Severe Sequelae from Augmentation Mammaplasty 596
Introduction 596
Historical Background 596
Timing of the Operation 597
Anatomic Considerations 597
Step-by-Step Surgical Technique 598
Other Surgical Options 599
Conclusions 599
References 602
Idiosyncratic Allergic Reaction: A Rare Complication of Augmentation Mammoplasty 604
Introduction 604
Case Reports 604
Discussion 605
Conclusion 606
References 606
Complications of Silicone Gel Implants 610
Introduction 610
Seroma 610
Hematoma 610
Infection 611
Capsular Contracture 612
References 615
Aesthetic Management of the Breast Capsule After Explantation 617
Introduction 617
Histology 617
Discussion 618
Conclusions 618
References 618
Complications of the Transumbilical Approach 620
Introduction 620
Incorrect Implant Pocket Position 620
Reports of Complications 620
References 621
Implant Postoperatively too High 621
Capsule Contracture 621
Subfascial Breast Augmentations: Complications 622
Introduction 622
Reported Complications 622
Difficulty Dissecting the Pocket 622
Incorrect Pocket 622
Discussion 622
Conclusions 623
References 623
Complications of Autologous Fat Transfer to the Breast 624
Introduction 624
Discussion 624
Reported Complications 624
References 624
Miscellaneous 625
Breast Conservation Therapy After Augmentation Mammaplasty 626
Introduction Definition 626
Oncologic Consultation: Treatment Alternatives 626
Lumpectomy: Effect of Breast Implants on Mammography 627
Lumpectomy: Effect of Radiation on Rate of Capsular Contracture 627
Lumpectomy and Radiation Versus Glandular Replacement Therapy 628
Breast Conservation Therapy in the Augmented Patient: Clinical Experience 629
Conclusions 630
References 631
Serologic and Histologic Findings in Capsule Contracture Patients with Silicone Gel Implants 632
Introduction 632
Investigations, Results, and Discussion 632
Conclusions 636
References 637
Medical-Legal Aspects of Breast Augmentation 638
Introduction 638
Requirements for Medical Negligence 638
Standard of Care 638
Informed Consent 638
Complications 639
The Angry Patient 639
Patient Rapport 639
Medical Record 640
Legal Aspects 640
Legal Cases 640
The Misinformed Expert Witness 640
Discussion 643
References 643
Editor’s Commentary 644
Introduction 644
Retropectoral Versus Retromammary Breast 644
Implantation 644
Capsulectomy Versus Capsulotomy for the Treatment of Capsular Contraction 644
Capsule Contracture After Breast Irradiation for Cancer 644
Antibacterial Irrigation in Pocket Under or Over the Pectoralis Major Muscle: Before Insertion of Prosthesis Capsule Contracture Rates 645
Umbilical Approach to Breast Augmentation 645
Textured Versus Smooth Implants 645
Treatment of Implant Pocket Infection 645
Comparison of the Mentor Siltex Textured Implant and the McGhan BioCell Textured Implant 645
Autologous Fat Augmentation of the Breast 646
The Perfect Breast 646
References 646
Subject Index 648

Initial Consultation (p. 69-70)

Melvin A. Shiffman

10.1 Introduction

The initial consultation with a patient considering breast augmentation should be complete. The patient will be impressed if a proper history and examination are performed and will be more likely to schedule the surgery. Enough information from the patient should be requested to be able to evaluate whether or not to perform the surgery.

10.2 Subjective Reasons for Breast Augmentation

The patient is the only one to decide whether augmentation is necessary. Surgeons should avoid the patient who has a body dysmorphic disorder and is seeking a surgery that may minimally, if at all, improve the body. This becomes more important when revision may be necessary. Very minor corrections should be avoided. A significant number of patients will need surgical correction of the augmentation for asymmetry, contracture, ptosis, infection, or necrosis. The more breast surgeries performed on a patient, the more likely the complications.

10.3 History

The patient’s past history should be obtained, at least including past surgeries of the breast and chest, bleeding or bruising tendencies, pulmonary or heart disorders, and prior thromboembolism. The date of her last menstrual period should be requested.. Medications being taken should be listed, including aspirin, Coumadin, nonsteroidal anti-inflammatory drugs, estrogen, and herbals. If the patient presently smokes cigarettes, this may impact wound healing and may cause necrosis. A history of diabetes mellitus is important because uncontrolled diabetes increases the risk of slow healing and wound infection. The surgeon should have an internist check the blood sugar preoperatively and follow blood sugar on a daily basis for at least 7 days postoperatively and then on a regular basis.

history of breast cancer should be taken very seriously. The patient should have a checkup by the oncologist to make sure that metastases have not occurred, and recent mammogram report should be obtained or a mammogram ordered to make sure there are no suspicious areas in either breast. If lumpectomy has been performed followed by radiation, there is a reasonable assumption that the breast tissues have a decreased blood supply from the radiation. Therefore, healing will slower, and there is a greater risk of necrosis. Incisions near the area of the incision site for the lumpectomy, where increased radiation has been used, should avoided because healing will be very prolonged, and chance of wound breakdown increases.

The family history should include at least cancers the breast, blood dyscrasias, and thromboembolism. Patients with a strong familial history of breast cancer should be counseled about the possibility of future breast cancer and the effects of the presence of an implant in the submammary position possibly decreasing chance of early diagnosis.

10.4 Physical Examination

physical examination should include at least the heart and lungs as well as the breast and axilla. The breasts should be examined both in the sitting and supine position with the arms over the head (this flattens the breast against the chest wall). Observe the breast for skin or nipple indentations and asymmetry. Check for masses in the breast and axilla, tenderness, induration. Record the following measurements: Sternal notch and/or midclavicle to nipples Nipples to midline Extent of ptosis: either the degree and/or measurement from nipple to inframammary fold and inframammary fold to lowest point of breast

10.5 Informed Consent

Informed consent requires that the patient receive enough information about the surgical procedure proposed and the alternatives as well as the possible risks and complications of each so that a knowledgeable decision can be made.

10.6 Implants

Evaluation for implant size may be performed in the office with the use of various sizes of implants, or baggies filled with water of different amounts, placed in the brassiere and using a mirror to determine what looks best. The patient can use baggies at home in order to consider the proper size, and she can bring in photos of topless women whose appearance she desires. The surgeon should make sure that the patient decides on the size and is not influenced by her spouse or boyfriend. The patient’s own body image should be the determining factor. The surgeon and office staff should also not influence the patient as to size.

The type of implant―smooth or textured, silicone or saline―should be described along with its pros and cons. The position of the implants, above or below the muscle, should be discussed as well as the surgical incision site―axillary, periareolar, intraareolar, inframammary, and possibly the umbilical approach.