eMedicine Specialties > Plastic Surgery > Breast
Breast Augmentation, Submuscular: Treatment
Updated: Apr 7, 2006
Treatment
Surgical Therapy
Placement Route
Implants may be placed by a number of routes that typically vary with surgeon preference and experience. The individual's desired results may influence the site of implant placement.
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, in general, 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 around the difficulty in placing the incision in the inframammary crease, which potentially is exacerbated with low-profile implants.
Periareolar approach
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 areolar avoids the fourth intercostal nerve, which supplies sensation to the nipple and areola.
Transaxillary approach
Placing incisions in the axilla, referred to as a transaxillary approach, avoids placement of the scar on the breast. The transaxillary approach provides the worst exposure for placement of the implant, which is a disadvantage. This may be avoided using special instrumentation, including endoscopes and specific surgical instrumentation designed to aid the dissection. An increased incidence of paresthesia involving the nipple-areolar complex exists with this approach. Obtaining symmetric pockets is more difficult, and damage to the intercostal brachial nerve and subclavian venous thrombosis has been reported with this technique. Additionally, if infection results, removal of the implant may require conversion of the transaxillary incision to one of the other incisions listed above. Hypertrophic scar formation also can occur in the axilla, and the incision may be visible when the patient wears a sleeveless dress and elevates her arms.
Periumbilical approach
A periumbilical approach, involving placement through the umbilicus, can be used for augmentation of the female breast. 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 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 or in a plane below the pectoralis major muscle. Advantages attributed to placement below the gland include ease of dissection, predictable sizing and contouring, and satisfactory results provided capsular contracture does not occur. Placement of larger implants in a subglandular position than in a submuscular position is also feasible.
(Above) A 24-year-old woman with an A-cup breast. (Below) Postoperative result after subglandular placement with 460-cc implants. Note the lower position of the implant when placed subglandularly.
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.
(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.
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.
Disadvantages 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, detach the inferior portion of the pectoralis musculature 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 typically 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, drain it 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, drain and irrigate the wound. Removal of the implant may not be necessary, particularly if a periareolar incision was used with initial surgery. Prescribe antibiotics 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. For more information, see eMedicine Infectious Diseases article Staphylococcal Infections.
Sensory changes
Changes in nipple-areolar sensation are common postoperatively 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 and/or breast prosthesis.
Contour irregularity and implant extrusion
Contour irregularity and implant extrusion also are rare events that may be associated with the placement of implants. The most common cause of contour irregularity is a tight capsular contracture that may develop around the implant.2 A wide range of incidence of capsular contracture, from 0-74% of patients, has been noted following breast implantation. The incidence of capsular contracture appears to be approximately 30% of individuals who have undergone the procedure. Classification of the contracture is highly subjective. In 1980, Little and Baker developed a classification for the capsular contracture present in patients following breast augmentation, which remains the standard for evaluating this complication in patients. The grades of capsular contracture are divided into 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.
Subclinical infection may cause capsular contracture, with S epidermidis the most probable etiologic agent. Various techniques, including massage, which expands the size of the capsule, attempt to reduce the incidence of this complication. The role of antibiotics in the prevention of capsular contracture is unclear. Antibiotics may benefit if subclinical infection is a factor. However, in patients in whom this is not a problem, antibiotics provide no benefit to the individual. Capsule formation may require surgical capsulotomy, which involves circumferential and radial division of the capsule. In addition, the extent of the pocket is increased. Recurrence following capsulotomy approaches 30%. Complications of capsulotomy include bleeding, infection, and implant exposure.
In addition, 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, but they are currently available for this problem only with investigators in an approved protocol by the manufacturer.
Medicolegal pitfalls
Medicolegal pitfalls typically are concerned with informed consent. Discuss previously enumerated complications preoperatively. Recently, the Food and Drug Administration approved saline implants, but not for use in minors or via a periumbilical approach.
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References
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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
