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Breast Augmentation, Submuscular
Updated: Apr 7, 2006
Introduction
Breast surgery is performed to enhance the size and shape of a woman's breasts. Surgery typically improves the individual's self-image. Historically, breast enlargement was accomplished by 1 of 3 methods, with varying results of success.
- Inert material such as silicone and paraffin has been injected directly into the parenchymal tissue to increase breast size. This method was abandoned because of the exceedingly high incidence of both acute and long-term complications. Granulomas are frequent from this procedure, as are complications of skin loss and scar contracture producing excessive disfigurement.
- Autogenous tissue injections also have been used in an attempt to enhance and enlarge the shape of a woman's breasts. Autogenous tissues, including omentum, fat, muscle, lipomas, and skin in the form of dermis and dermal fat grafts, have been used to enhance and enlarge the breasts. Results from injection of autogenous tissue have not been positive or predictable. In addition to scarring and uneven texture that may be visible in patients who have undergone tissue injection into the breasts, microcalcifications develop. This makes performing follow-up mammography on these women for early diagnosis of breast cancer impossible.
- Recently, a suction pump device was used to attempt to enhance the shape of women's breasts. However, while some enlargement was noted, the overall aesthetic shape in these individuals was lacking significantly.
Implants have been used since the 1960s to enhance and enlarge the shape of female breast tissue. Currently, they are the preferred approach for augmentation mammaplasty. First used in 1964, when reported by Cronin and Gerow, silicone still is used for augmentation of female breasts.1 The advantages of silicone-filled implants include minimum solubility of the silicone and excellent viscosity of the material, providing an excellent feel to the breasts. Problems associated with silicone implants include capsular contracture, granulomas that develop following leaching of silicone from the implant, and migration of silicone into the axilla. Autoimmune responses have been reported regarding silicone implants in breast augmentation. These were discredited because of a number of exhaustive long-term studies that failed to demonstrate increased incidence of long-term problems in large numbers of women who underwent augmentation with silicone implants.
When the Food and Drug Administration (FDA) temporarily removed silicone implants because of purported increased incidence of autoimmune phenomena, a considerable amount of interest arose regarding the use of saline implants to augment breast tissue. Saline-filled implants have been used since the 1960s. Saline is absorbed safely into the bloodstream if a loss in the integrity of the implant capsule develops. Saline commonly is used in intravenous (IV) solutions and poses no risk to patients.
Saline implants purportedly have a decreased capsular contracture rate when compared with silicone implants. However, saline has slightly decreased viscosity compared to silicone. The initial use of saline implants resulted in a high incidence of deflation (approximately 10%). Over the last 10 years, significant work by implant manufacturers to improve the integrity of implants and specifically to improve the reliability of the valvular mechanism for introduction of saline into the implant has resulted in deflation rates that are predicted to be less than 1%.
After having been removed from general use by the FDA, silicone implants have been exhaustively studied and have been shown to have low complication rates comparable with or, in some cases, lower than those of saline implants. The FDA subcommittee on silicone implants has recommended that silicone implants be reintroduced in the United States. Silicone implants were never removed from the European market.
History of the Procedure
Implants may be either round or teardrop shaped. Round implants are disc shaped and exhibit equal fullness in all 4 quadrants of the breast.
(Above) Preoperative view of 28-year-old woman with micromastia. She has had 2 children. Note the small breast has decreased upper pole fullness. (Below) Postoperative view after submuscular augmentation with a round implant. Notice increased fullness of the upper poles of the breasts. Submuscular placement makes it difficult to appreciate the edge of the implant.
Teardrop or anatomic implants exhibit reduced augmentation fullness in the upper pole of the breast with increased fullness in the lower half of the breast. These implants also are narrower at the superior and inferior poles than rounded implants.
(Above) Preoperative view of 26-year-old woman with minimal upper pole fullness and asymmetric breasts. (Below) Postoperative result after submuscular placement of anatomically shaped implants. Notice increased lower pole fullness and absence of upper pole fullness relative to the round implant shown in Image 1.
The implant capsule may be smooth or textured. Textured implants initially were developed as an alternative to polyurethane-covered silicone gel implants, which first were introduced in the early 1970s. Initial reports indicated polyurethane-covered silicone gel implants resulted in decreased capsule formation. Ingrowth of scar tissue into the polyurethane surface was postulated to break up the vector forces of scar contracture. Because of the altered vectors of scar contracture, the capsule of the scar was unable to contract to the same degree as typically present around a silicone implant; however, this theory never was proven definitively in a scientific study.
However, it became clear that polyurethane underwent microfragmentation and phagocytosis. In addition, the polyurethane possibly would break down and dissolve within the tissue locally after placement of these implants. An intense foreign-body reaction with numerous macrophages and multinucleated giant cells occurred in the capsule in some patients who had this type of implant.
Because of these problems, implants with a polyurethane-covered coat were removed from the market. The implant manufacturers, in an attempt to duplicate the potentially protective value with regard to capsular contracture in polyurethane-covered silicone gel implants, sought to increase the wall of standard saline implants to duplicate the effect noted with polyurethane. This same approach also was attempted in silicone implants. Unfortunately, results from increasing the capsular thickness with surface texturing have not conclusively decreased capsular contractures in patients undergoing breast augmentation. Reports of increased wrinkling because of placement of textured implants in individuals undergoing breast augmentation have been noted.
Contraindications
Severe ptosis is a relative contraindication to surgery. Women with significant ptosis may require a mastopexy concomitantly or as a secondary procedure. Women with tubular breasts also are at significant risk of secondary procedures after the augmentation to correct residual deformities secondary to the original tubular shape of the breast. Evaluate severe associated medical conditions on a patient-by-patient basis, as with any surgery.
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References
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Asplund O. Capsular contracture in silicone gel and saline-filled breast implants after reconstruction. Plast Reconstr Surg. Feb 1984;73(2):270-5. [Medline].
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Oneal RM, Argenta LC. Late side effects related to inflatable breast prostheses containing soluble steroids. Plast Reconstr Surg. Apr 1982;69(4):641-5. [Medline].
Rees TD, Guy CL, Coburn RJ. The use of inflatable breast implants. Plast Reconstr Surg. Dec 1973;52(6):609-15. [Medline].
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Tebbetts JB. Transaxillary subpectoral augmentation mammaplasty: long-term follow-up and refinements. Plast Reconstr Surg. Nov 1984;74(5):636-49. [Medline].
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. Dec 2005;116(7):2005-16. [Medline].
Further Reading
Keywords
breast augmentation, submuscular breast augmentation, breast implant, inframammary approach, periareolar approach, transaxillary approach, periumbilical approach, subglandular, implant rippling, micromastia, breast surgery, breast enlargement, silicone implants, gel implants, saline implants, submuscular
