eMedicine Specialties > Plastic Surgery > Breast
Breast Augmentation, Submuscular
Updated: Nov 9, 2009
Introduction
Breast augmentation is usually performed to enhance the size and shape of a woman's breasts. Surgery can often improve an individual's self-image. Historically, breast enlargement was accomplished by 1 of 4 methods, with varying degrees of success.
- Inert materials such as silicone or paraffin have been injected directly into the parenchymal tissue to increase breast size. This method was abandoned because of the exceedingly high incidence of acute and long-term complications. Granuloma formation frequently occurs with this procedure, as well as skin loss and scar contracture, producing disfigurement.
- Autogenous tissue injections also have been used in an attempt to enhance and enlarge the breast shape. Autogenous tissues, including omentum, fat, muscle, lipomas, and skin, in the form of dermis or dermal fat grafts, have been used to enhance and enlarge the breasts. Results from injection of autogenous tissue have lacked predictability. In addition to the risks of scarring and uneven texture that may be visible in patients who have undergone tissue injection into the breasts, microcalcifications may develop. This makes performing follow-up mammography on these women for early diagnosis of breast cancer difficult.
- Recently, a suction pump device was used to attempt to enhance the breast shape. However, while some enlargement was noted, the overall aesthetic shape in these individuals was lacking significantly.
- Implants filled with a substance can be placed to enhance and enlarge the size of the breast.
Implants, most often filled with either silicone or saline, have been used since the 1960s to enhance and enlarge the shape of female breast tissue. Currently, they are the preferred method for augmentation mammaplasty.
History of the Procedure
Both saline-filled and silicone-filled implants have been used since the 1960s to enhance and enlarge women's breasts. Initial silicone implants in the early 1960s had a thick elastomer shell and were filled with a relatively firm silicone gel. In the mid 1970s, silicone implants tended to have a thin elastomeric shell and a less viscous gel, though gel cohesiveness was varied. Over the years, modifications have been made to implant shape, shell texture and properties, and the substance with which the implant is filled.
Implant shape
Implants can be 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-shaped implants (also called anatomic implants) exhibit reduced augmentation fullness in the upper pole of the breast and increase fullness in the lower half of the breast. These implants are narrower than rounded implants at the superior and inferior poles. In some cases, implant rotation can be a problem with teardrop-shaped 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.
Shell texture and properties
Polyurethane-covered silicone gel implants were first introduced in the early 1970s.
Initial reports indicated that 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.1,2
Over time, however, polyurethane underwent microfragmentation and phagocytosis. In addition, the polyurethane could break down and dissolve within the local tissue after implant placement.3 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, polyurethane-covered implants were removed from the market. In an attempt to duplicate polyurethane’s potential protection against capsular contracture, Implant manufacturers increased the shell thickness of standard saline and silicone implants with surface texturing. Unfortunately, shell texturing has not conclusively decreased capsular contractures in patients undergoing breast augmentation. Increased wrinkling due to textured implants has been reported.
In the late 1980s and into the 1990s, multi-layered shells were developed. These have a barrier layer to reduce silicone leakage from the implant. The alteration in the elastomer shell composition was accompanied by the introduction of a firmer gel. The firmer gel has multiple crosslinks between the silicone molecules to obtain a cohesive effect, which reduces the capacity of the gel to migrate significantly if the integrity of the shell is compromised.
Silicone vs saline
Silicone implants were first used in 1964, when reported by Cronin and Gerow, and they are still used for breast augmentation today.4 The advantages of silicone-filled implants include the minimal solubility of silicone and favorable viscosity of the material, which, together, provide a natural feel. The initial silicone implants were composed of a thick outer elastomer shell that was then filled to variable volumes with a silicone gel. 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. In 1992, the Food and Drug Administration (FDA) temporarily removed silicone implants because of a purported increased incidence of autoimmune phenomena.
Saline implants had also been in use since the 1960s, but the removal of silicone implants from the market in 1992 increased interest in saline implants. The advantages of saline-filled implants are that saline poses no risk to patients and is safely absorbed into the bloodstream if the integrity of implant capsule is compromised. Some studies report that saline implants have a decreased capsular contracture rate compared to silicone implants. However, saline has slightly decreased viscosity compared to silicone. The initial use of saline implants has resulted in a high incidence of deflation (approximately 10%). Over the last 10 years, implant manufacturers have significantly improved the integrity of implants; specifically, the reliability of the valvular mechanism for introduction of saline into the implant. Late deflation of saline-filled implants, however, remains a significant issue.
After having been removed from general use by the FDA, silicone implants were exhaustively studied and have been shown to have low complication rates comparable with or, in some cases, lower than those of saline implants (see discussion below). The reported autoimmune responses were discredited by numerous 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.
In 1999, the National Academy Institute of Medicine issued a report that concluded "because there are more than 1.5 million adult women of all ages in the United States with silicone breast implants, some of these women would be expected to develop connective tissue diseases, cancer, neurological diseases, or other systemic complaints or conditions. Evidence suggests that such diseases or conditions are no more common in women with breast implants than in women without implants."5
In the United States, breast cancer presents in approximately 1 out of 9 women (11%). Breast implants are not associated with an increased frequency of breast cancer. Because of the large number of patients undergoing augmentation and the relatively high frequency of breast cancer, some augmentation patients will eventually develop breast cancer. Patients who have undergone breast augmentation and develop breast cancer do not experience delayed detection or poorer survival than the general population.6,7 The National Cancer Institute recently completed a study of over 13,000 women who placement of silicone implants and concluded that there was no significant increase in either breast cancer incidence or mortality.8
In 2006, the FDA approved implants filled with silicone gel (from Mentor Corporation and Allergan) for augmentation and reconstructive purposes in the United States.9 Silicone implants were never removed from the European market. For complete information on the silicone safety, see eMedicine article Breast Implants, Safety and Efficacy of Silicone.
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.
As with any surgery, severe associated medical conditions need to be evaluated on a patient-by-patient basis.
Treatment
Surgical Therapy
Surgical approaches for breast implant placement include inframammary, periareolar, transaxillary, and periumbilical. Several issues contribute to the choice of approach, including surgeon preference and experience.
Three basic configurations of shapes are currently available for breast augmentation. The shapes of the implants are most easily described as low-, medium-, and high-profile. A low-profile implant has a broader base and lower height when viewed on a table next to a high-profile implant of comparable volume (a medium-profile implant has base and height dimensions in between the two).
Silicone implants require a larger incision for placement than do saline implants. Silicone implants are prefilled and are, therefore, available in fixed volumes, in contrast to saline implants, which are filled after they are placed in the patient and may be adjusted to compensate for any difference in volume between the patient's two breasts.
Inframammary approach
An inframammary incision is the most common approach for placement of a breast implant. This approach, which entails a 3- to 4-cm incision, attempts to place the incision in or adjacent to the inframammary crease. The inframammary approach provides the most direct route and generally requires the least operative time for placement of the implant. Problems associated with inframammary incisions include a visible scar on the anterior surface of the breast. Additional problems center on the difficulty in placing the incision in the inframammary crease; this difficulty is potentially exacerbated with low-profile implants.
Periareolar approach10
Implants placed by an incision within the pigmented areolar tissue, referred to as a periareolar incision, often result in the least conspicuous scar. However, dissection of the pocket required for implant placement is more difficult with a periareolar incision. Dissection must proceed through a portion of the breast tissue or in the subcutaneous plane. Problems with subcutaneous dissection include nodularity and inflammation. Incisions placed through the breast tissue or in the subcutaneous plane are associated with microcalcification and cyst formation. Medial placement of the periareolar implant incision within the areola avoids the fourth intercostal nerve, which supplies sensation to the nipple and areola.
Transaxillary approach11
In the transaxillary approach, incisions are placed in the axilla, which avoids placement of the scar on the breast.12 However, the transaxillary approach provides the worst exposure for placement of the implant. This may be avoided using special instrumentation, including endoscopes and specific surgical instrumentation designed to aid the dissection.12 An increased incidence of paresthesia involving the nipple-areola complex exists with this approach has been reported; however, the author has not experienced this complication.
Obtaining symmetric pockets is more difficult with this approach, and damage to the intercostal brachial nerve and subclavian venous thrombosis has been reported. Additionally, if infection results, removal of the implant may require conversion of the transaxillary incision to one of the other incisions described. Hypertrophic scar formation also can occur in the axilla, and the incision may be visible when the patient elevates her arms while wearing a sleeveless shirt. Because silicone implants are prefilled and, therefore, require a larger incision for placement, only smaller silicone implants are typically placed via this route.
Periumbilical approach
A periumbilical approach, involving implant placement through the umbilicus, can also be used for augmentation. Placement of the implant is restricted to a prepectoral plane, and this approach provides the worst control for dissection of the pockets. Superior dissection and symmetry of placement are difficult, even in the most experienced hands. Complications of hematoma or infection require conversion to one of the other incisions for implant removal. Additionally, placement of saline-filled implants through a periumbilical approach requires a special type of valvular mechanism, and the long-term reliability of the valvular mechanism in these implants has not been fully clarified, at least to the author's satisfaction.
Implant placement
Implants may be placed directly beneath the mammary gland (subglandular) or in a plane below the pectoralis major muscle (submuscular). Advantages attributed to placement beneath the gland include ease of dissection, predictable sizing and contouring, and satisfactory results, provided that capsular contracture does not occur. The subglandular position also allows for placement of larger implants than are feasible in a submuscular position.
(Above) A 24-year-old woman with an A-cup breast. (Below) Postoperative result after subglandular placement with 460-mL implants. Note the lower position of the implant when placed in a subglandular position.
Submuscular placement of implants was developed in response to problems associated with subglandular placement, specifically, capsular contracture and visibility of the edge of the implant. Additional benefits attributed to submuscular placement include reduced sensory changes in the nipple, decreased rates of capsular contracture, and ease of interpretation of mammographic studies. The submuscular plane is avascular, and incidence of hematoma may be reduced by placement in the submuscular plane.
Submuscular breast implants can be placed completely or only partially below the muscle. In total submuscular placement, the implants are located beneath both the pectoralis major muscle and the anterior portion of the serratus magnus muscle. With subpectoral placement, the implant is placed behind the complete pectoralis major muscle. The third option has been described as the dual plane approach.13 As initially described, in the dual plane approach, the implant is placed under the superior portion of the pectoralis major muscle; inferiorly, the implant is placed in a subglandular plane. In some patients, this result is incidentally achieved because of the size of the pectoralis major muscle, while in other patients, the pectoralis major muscle is cut in the middle of the body of the muscle to facilitate implant placement. Surgeon experience, lower breast pole anatomy, and the patient's desired results may dictate the choice of implant placement.
(Above) Preoperative view of a 27-year-old patient desiring augmentation. (Below) Postoperative view after augmentation with a round implant. Notice the smooth contour in the upper pole. The end of the implant is not perceptible because of submuscular placement.
Disadvantages of submuscular implant placement include potential limitations on the size of the implant, increased postoperative pain, and the possibility of lateral displacement of the implant. In addition, obtaining significant cleavage is more difficult with submuscular placement. If significant cleavage is desired, the inferior and/or medial portion of the pectoralis musculature must be detached from its sternal attachments. This results in increased postoperative discomfort.
(Above) Preoperative view of 23-year-old patient with micromastia. (Below) Postoperative view after augmentation with detachment of the inferior half of the pectoralis musculature from the sternal attachments to provide cleavage. Note increased medial projection.
Complications
Hematoma
The frequency of hematomas is less than 2%. Associated symptoms of hematoma are unilateral pain, swelling, and, occasionally, fever. Hematomas may develop slowly without symptoms or rapidly with symptoms. Small hematomas may resolve without intervention, but large hematomas require drainage. Often, delaying drainage until liquefaction of the clot has occurred is preferable. However, if the hematoma is painful or large, it should be drained immediately.
Infection
Incidence of infection is approximately 2%. Infection typically becomes apparent 7-10 days postoperatively but may manifest at any point. Typical presenting symptoms of infection include swelling, discomfort, pain, drainage, and cellulitis overlying the breast. Typically, the wound should be drained and irrigated. Removal of the implant may not be necessary, particularly if the original surgery was by periareolar incision.14 Antibiotics should be prescribed immediately. If the implant is not removed, infection may result in severe capsular contracture. If the implant is removed following infection, it typically is replaced in 3-6 months. Staphylococcus epidermidis or Staphylococcus aureus commonly may cause infections.14 For more information, see eMedicine Infectious Diseases article Staphylococcal Infections.
Sensory changes
Postoperative changes in nipple-areolar sensation are common in patients who have undergone breast augmentation. Most patients exhibit a temporary dysesthesia, which tends to resolve in a period of months. However, a small percentage of individuals may present with long-term sensory changes in one or both nipples following breast augmentation. An increased incidence of sensory changes is noted with transaxillary augmentation, since this approach directly crosses the fourth intercostal nerve, which supplies sensation to the nipple-areolar area.
Scars
Hypertrophic or keloid scar formation is uncommon following breast augmentation. The lowest incidence of hypertrophic scarring appears in periareolar incisions. The presence of a hypertrophic scar in inframammary or axillary incisions may require re-excision and closure of the incision.
Asymmetry
Asymmetry of the implant position may result from shifting of the implant, increased contraction of the capsule unilaterally, or ptosis of the implant, which is attributed to placement of steroids in the pocket or breast prosthesis.15
Contour irregularity and implant extrusion
Contour irregularity and implant extrusion may rarely be associated with the placement of implants. The most common cause of contour irregularity is a tight capsular contracture that develops around the implant.16 The incidence of capsular contracture following breast implantation appears to be approximately 30% of patients, but the reported incidence has varied widely, from 0-74% of patients. Classification of the contracture is highly subjective. In 1980, Little and Baker developed a classification system for capsular contracture following breast augmentation; it remains the standard for evaluating this complication. The grades of capsular contracture are divided into the following 4 types:
- Grade I: Capsular contracture of the augmented breast feels as soft as an unoperated breast.
- Grade II: Capsular contracture is minimal. The breast is less soft than an unoperated breast. The implant can be palpated but is not visible.
- Grade III: Capsular contracture is moderate. The breast is firmer. The implant can be palpated easily and may be distorted or visible.
- Grade IV: Capsular contracture is severe. The breast is hard, tender, and painful, with significant distortion present. The capsule thickness is not directly proportional to palpable firmness, although some relationship may exist.
Various techniques, including massage, which expands the size of the capsule, attempt to reduce the incidence of this complication. Capsule formation may require surgical capsulotomy, which involves circumferential and radial division of the capsule and an increase in the extent of the pocket. Recurrence following capsulotomy approaches 30%. Complications of capsulotomy include bleeding, infection, and implant exposure. Capsulectomy, in which the capsule is excised, is also an option. A capsulectomy may be of benefit in some instances in which capsulotomy has failed or in cases of silicone implant rupture. The surgeon may also perform capsulectomy when a highly calcified capsule is present. Zafirlukast (Accolate), which causes smooth muscle relaxation, has been useful in some instances of capsular contracture and may obviate the need for surgery in select individuals.
Contour irregularities may arise because of rippling of the implant. Individuals with thin skin are more susceptible to this problem. Silicone implants seem to be subject to less rippling than saline implants. Numerous investigators are currently examining the role of fat injection to minimize contour irregularities, enhance breast symmetry, and reduce the visibility of rippling.
Medicolegal pitfalls
Medicolegal pitfalls typically relate to informed consent. The complications outlined above should be discussed with the patient preoperatively.
Outcome and Prognosis
Despite the extensive list of potential complications, breast augmentation remains one of the safest and most predictable procedures performed. The surgery provides a balance between the size and shape of the patient's breasts and the rest of her body. The low incidence of complications and the predictability of surgical outcome have prompted an increasing number of individuals to undergo the procedure.
Multimedia
Media file 1: (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.
Media file 2: (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.
Media file 3: (Above) A 24-year-old woman with an A-cup breast. (Below) Postoperative result after subglandular placement with 460-mL implants. Note the lower position of the implant when placed in a subglandular position.
Media file 4: (Above) Preoperative view of a 27-year-old patient desiring augmentation. (Below) Postoperative view after augmentation with a round implant. Notice the smooth contour in the upper pole. The end of the implant is not perceptible because of submuscular placement.
Media file 5: (Above) Preoperative view of 23-year-old patient with micromastia. (Below) Postoperative view after augmentation with detachment of the inferior half of the pectoralis musculature from the sternal attachments to provide cleavage. Note increased medial projection.
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Keywords
breast augmentation, submuscular breast augmentation, breast implant, inframammary approach, periareolar approach, transaxillary approach, periumbilical approach, implant rippling, micromastia, breast surgery, silicone implants, gel implants, saline implants
Contributor Information and Disclosures
Author
Jay M Pensler, MD, Aesthetic Plastic and Reconstructive Surgery, Private Practice; Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, Northwestern University Medical School
Jay M Pensler, MD is a member of the following medical societies: American Academy of Pediatrics, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, and Sigma Xi
Disclosure: Nothing to disclose.
Medical Editor
Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
CME Editor
Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.
Chief Editor
James Neal Long, MD, Assistant Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of Alabama at Birmingham and Kirklin Clinics
James Neal Long, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.