eMedicine Specialties > Plastic Surgery > Breast
Uses of the Postoperatively Adjustable Implant in Aesthetic Breast Surgery
Updated: Aug 13, 2008
History and Evolution
Breast augmentation or reduction has a relatively short history. The breast has been synonymous with femininity in many cultures almost from the beginning of recorded human history. While preferred breast size varies according to the fashion of the times, increasing or decreasing breast size was not possible until relatively recent times. However, based on images from antiquity, one can appreciate that breast appearance has been both accentuated and diminished according to fashion over the years.
Czerny made the first recorded surgical attempt to enlarge the breast in 1895, when he transplanted a lipoma from the back of an actress to her breasts. The long-term results of this procedure can only be assumed. Gersuny tried paraffin injections in 1889, with disastrous results. In recent history, various creams and medicaments have been used in attempts to increase bust size. Berson in 1945 and Maliniac in 1950 performed a dermal-fat flap. Pangman introduced the Ivalon sponge in 1950, and various synthetics were used throughout the 1950s and 1960s, including silicone injections. All of these attempts resulted in long- and short-term disasters.
In 1963, Cronin and Gerow developed the first silicone gel breast implant with the Dow Corning Corporation, ushering in the era of reliable breast augmentation.1 Various types of silicone gel implants were then developed by manufacturers all over the world. Inflatable saline implants and others containing a combination of gel and saline came into use in the 1970s. In 1982, Radovan developed the first generation of temporary tissue expanders for reconstructive uses, and the concept of tissue expansion was born.2
In 1984, Becker, in conjunction with the Mentor Corporation, developed the first permanent tissue expander designed specifically for the breast, primarily for breast reconstruction after mastectomy.3 The Becker expander soon found use in breast augmentation in the late 1980s, giving rise to the concept of breast expansion-augmentation. The use of this implant was curtailed after the implant crisis in 1991, but it was supplanted by the Spectrum implant, which is a permanent saline expander with the Becker valve, fill tube, and reservoir system. While the gel/saline Becker is still available for use (with US Food and Drug Administration [FDA] restrictions), cost is the primary reason it is unsuitable for use in breast expansion-augmentation. It has virtually been replaced by the Spectrum saline implant, which has no peer as a combined permanent breast implant and expander.
Indications for the Procedure
While breast augmentation is a fairly straightforward and simple procedure, many issues related to size, shape, symmetry, or scarring can lead to unpredictable and undesirable results. In these instances, breast expansion-augmentation offers a viable and predictable alternative.
Size
Saline augmentations of the breast have been more common in the United States since the FDA banned silicone gel implants in 1991. They were readmitted to the market in 2006. (For more information, see Breast Implants, Silicone: Safety and Efficacy.) At first, surgeons treated saline augmentations as if they were the same as gel augmentations. Time and experience have taught that preoperative planning and intraoperative technique differ between saline implant and gel implant placement.
Some features of the saline implant differentiate them from the gel implants. The issues of feel, palpability, and rippling seem to mandate that the saline implant be placed beneath the pectoralis muscle rather than above it. In addition, texturing of the implant surface has reduced the gel implant's high rate of fibrous contracture when implanted in the subglandular position. Texturing of the saline implant surface has not proved advantageous and may even contribute to implant rupture through fold failure. The obvious limitation to using gel implants is the inability to adjust the volume within these implants.
When using a saline implant in the totally submuscular position, augmentation size can become a deciding factor because of the relatively noncompliant nature of the muscle cover. Once the maximum fill volume is obtained in a totally submuscular saline augmentation, the breasts assume a spherical shape and become firmer than a realistic breast, thus limiting the aesthetic result.
This problem can be compounded when performing a revision augmentation (such as, switching from a subglandular pocket to a submuscular one because of capsular scar tissue overlying the pectoralis muscle). The use of a partially submuscular or "dual plane" as advocated by Tebbets can allow one to place a larger implant; however, if larger than 400 mL, lower pole ptosis can occur along with "window-shading" of the pectoralis muscle. In this condition, the cut pectoralis retracts above the implant and, paradoxically, can push the implant downward upon forced contraction of the muscle.
The concept of tissue expansion is that as tissue is gradually stretched, it accommodates. If the tissue is stretched beyond a certain end point for a period of time and then the stretching force is reduced, tissue redundancy results. This concept is used in the breast expansion-augmentation technique. Implants are placed at surgery in the same fashion as any saline implant except that the microreservoir is attached to the fill tube and is implanted under the skin. The size required to achieve the desired result is decided preoperatively. The implant is initially filled at surgery to a comfortable size, and weekly expansions of 60-120 mL are performed, beginning after the first postoperative week. The reservoir is placed near the incision for easy removal later, without an additional scar.
To determine the necessary augmentation volume, the author begins with the simple formulation that each full cup size increase equals 200 mL. The next consideration is chest width. The patient's calculated volume requirement leads to an implant of a defined base width. If this base width is larger than the available chest width, then the author chooses a smaller implant with a narrower base width and plans on overfilling the implant. When the skin is excessively distensible and the parenchyma sparse, the patient is cautioned against going any larger than a full C cup (implant + parenchyma = 600 mL total volume).
After the decision has been made preoperatively that a certain size is required to achieve the desired result, the expansion is performed first to the desired size and then beyond that size for a period of time. The overfill is the amount by which the implant is filled beyond the manufacturer's published range. In most cases, the author overfills by 120-150 mL. This can be done in one setting in most patients.
In the average case (final implant size of 550 mL), the author takes an average of 4 filling sessions with the patient, as follows:
- Surgery – 240 mL
- 1st week – 360 mL (120 mL injected)
- 2nd week – 480 mL (120 mL injected)
- 3rd week – 600 mL (120 mL injected)
- 4th week - Overfill by 120 mL to a total volume of 720 mL
Overexpansion continues for 6 weeks on average. The excess fluid is then removed until the patient is satisfied with the size, shape, and softness of her breasts. The excess fluid that is drawn out of the implant creates the soft tissue redundancy that is expressed in the shape and softness of the resulting breast.
The reservoirs are usually removed shortly after completing the expansion process, once the patient is sure of her volume choice. Reservoirs are removed with the patient under local anesthesia. Berrino leaves the reservoirs in for an extended period for later adjustment of fluid volume.4 With the patient under local anesthesia, the removal can be performed in the treatment room or operating room through the prior incision, thus preventing the creation of a new scar.
Using this slow stretching of the breast, submuscular breast augmentation has virtually no size limitations. Additionally, with this technique, the patient becomes an active participant in the outcome of her own breast augmentation and ultimately will be happier with the result.
It should be clarified that, in most cases, the decision to use a Spectrum implant is based solely on the volume requirement of the proposed augmentation. Except in the setting of a augmentation mastopexy, the author does not typically use a Spectrum implant if less than 400 mL is calculated as the augmentation volume. The Spectrum implant could be used for augmentations less than 400 mL, but in the author's estimation, lower volume augmentations are not worth the increased cost and time of the Spectrum implant.
Shape
The shape of the breast during an expansion-augmentation can be affected by the amount of tissue redundancy created. Usually, shape is titrated with softness. The softer the resulting breast, the more natural it looks and the more like a real breast of a similar size it becomes. The firmer the breast, the rounder it appears. This titration occurs at the end of the process when the excessive fluid is removed. It can be affected by the ultimate size of the implant versus the manufacturer's recommended size (ie, if the final size is larger than the recommended final fill volume, the implant will naturally be more spherical). Further, it can be affected by the final volume obtained versus the amount of fluid removed, even within the manufacturer's recommendations.
The author prefers to remove no less than 100 mL and no more than 200 mL, and it is within this envelope that the titration of shape occurs. On occasion, loose skin from overexpansion may persist. A small excess can be improved with an increase in volume, but very often a short scar vertical mastopexy or circumareolar mastopexy may be required.
Symmetry
The expansion technique is used with greatest success in overcoming breast asymmetries, which can range from simple volumetric differences to much more complex issues involving volume, nipple position, implant base width, and ptosis or pseudoptosis. The artistic usage of an expandable implant can result in much greater breast symmetry without resorting to unilateral mastopexies or nipple lift procedures, which, in themselves, destroy symmetry.
If the breast with the higher nipple is overexpanded to a greater volume and for a longer time than the breast with the lower nipple, after release of fluid, the higher nipple falls farther, often creating improved symmetry. This fall is quite striking if the expansion occurs in the subglandular space on the affected side. Some descent is also possible in the submuscular position. Other asymmetries can also be "stretched out," and these include differences in roundness, inframammary crease position, size, and shape.
Scarring
The shape of the breast can be adversely affected by prior scar tissue from any number of causes, with fibrous encapsulation as the most frequent cause. A well-known phenomenon is that persistent stretching overcomes scar tissue and changes tissue shape. In the breast, scar tissue can limit the roundness of contour, which is considered an attractive trait. Expansion can restore proper shape to breasts that have become misshapen because of scarring. Further, if the problem is repeated fibrous encapsulation, overexpansion for a longer period (sufficient to obtain mature scar tissue) can overcome a recalcitrant fibrous capsule. In cases in which the goal of overfilling is to overcome the adverse scarring of fibrous encapsulation, the patient may be overfilled by 200 mL. The patient may be left overfilled for longer than 6 weeks.
The tuberous breast and pseudoptotic breast have an abnormally high inframammary crease that can result in a double-bubble effect if one simply places a submuscular implant below the natural inframammary crease. Expansion can also overcome this problem.
Another extremely useful feature of the expander is for the treatment of capsular asymmetries created by prior breast implant surgery. When performing an internal capsulodesis with a running or interrupted suture technique, the expander can be placed into the pocket greatly underinflated to avoid putting tension on the repair. The implant can remain underinflated for 3 weeks to allow for wound healing, and then it can be filled. Overfilling then overcomes slight irregularities in the contour that may have been created by the internal capsulodesis.
Mastopexy-augmentation
Often, using an implant with a mastopexy or with a breast reduction becomes necessary and desirable in order to achieve an optimal result regarding long-term breast shape. However, many plastic surgeons have experienced that the 2 procedures (ie, mastopexy and augmentation) are often at odds with each other. Performing the 2 procedures simultaneously can cause an increase in complications such as nipple-areola complex pedicle necrosis, implant dehiscence, and implant malposition. In some cases, the size of the chosen implant proves too large to permit proper wound closure.
The postoperatively adjustable feature of the expandable implant makes the combination procedure both safer and better. The same mastopexy technique normally chosen by the surgeon is used. The implant is placed into a totally submuscular pocket, which is closed with the fill tube externalized through the wound in the muscle. The author usually temporarily fills the implant to 300 mL and then performs the necessary glandular shaping inherent in the chosen mastopexy technique. The author then reduces the volume as needed to obtain a tension-free closure. The fill tube is cut, and the microreservoir is attached and placed into a subcutaneous pocket medial to the vertical incision. Postoperatively, it is filled in stages to the desired volume. Overfilling and releasing fluid, as described above in the expansion-augmentation technique, is not usually necessary.
Results
Please see the photograph series at the end of the article. The series illustrate the results obtainable with the expansion-augmentation technique and the Spectrum implant for mastopexy and augmentation.
With expansion, extremely large breasts can be created, if requested, because the manufacturer's recommended volume can be exceeded. In addition, always expect the patient to request a larger volume at the end than in the beginning. The patient in Image 13 requested a 2-cup increase, and the estimate was for a total of 850 mL, with a smaller implant to achieve greater roundness. The final volume was 1130 mL.
Complications
Images 1-2 reveal that from 1993-1999, the author performed breast augmentations on 480 patients (960 implants). Of these, 131 were expander patients (262 implants) and 349 were standard implant patients (698 implants). The complications studied were deflation, infections, capsular contracture, and reservoir extrusions.
Deflation
Overall, deflation occurred in 21 (2.1%) of 960 implants. For standard implants, deflation occurred in 13 (1.86%) of 698 implants over this 5-year period. For expanders, deflation occurred in 8 (3.05%) of 262 implants.
Infections
Overall, infections occurred in 6 (0.63%) of 960 implants. For standard implants, infections occurred in 5 (0.52%) of 960 implants. For expanders, infections occurred in 1 (0.1%) of 960 implants. For more information on surgical wound management, visit Medscape’s Wound Management Resource Center.
Capsular contractions
A total of 25 of the 960 implants had a Baker rating of higher than 2, yielding an overall rate of 2.6%. Of these, 15 of 698 were standard implants, yielding a rate of 2.1%. Ten of 262 were expanders, yielding a rate of 3.8%. The slightly higher rate for expanders can be partially attributed to the patient's desire to sacrifice size for softness.
Reservoir extrusions
This occurred in 2 (0.76%) of 262 expander implants.
Conclusions
The expansion-augmentation technique is a useful adjunct to breast augmentation and mastopexy-augmentation in selected patients and should be considered a part of every plastic surgeon's armamentarium. In difficult cases involving implant malposition, recurring fibrous capsular contracture, or asymmetry of volume or breast shape, these implants can make a very difficult case almost simple. Patients accept this technique readily and are uniformly happy with the results; they typically are especially happy to be a part of the size-related decision-making process.
Multimedia
 | Media file 1: Implantations from 1993-1999. |
 | Media file 2: Chart 2: Complications after 5 years. |
 | Media file 3: A 34-year-old woman with an A cup requested a C cup. Her volume is approximately 200 g of breast tissue; thus, she will require approximately 400 mL total (ie, 600-200 = 400). The 425+-mL Spectrum implants were chosen to allow for further increases. The postoperative views are after overexpansion for 6 weeks from the last fill with a volume of 660 mL, just prior to release of excess fluid on the right and after release of 120 mL on the left. The final volume is 540 mL. Note the softening effect. The profile view is breasts prior to fluid release. Note excess fullness of the upper pole of the left breast. Compare with profile views on the left after release of 120 mL. |
 | Media file 4: The patient is a 32-year-old nulliparous woman with 34AA cup. She wishes to be a full C cup. An estimate of volumetric requirements is 550-600 mL. The 475+-mL Spectrum implants were chosen. Postoperative views reveal a final volume of 660 mL after expansion to 780 mL for 6 weeks. |
 | Media file 5: A 25-year-old woman with a B cup requested D/DD breasts. The preoperative estimate was 500-600 mL, and 575+-mL Spectrum implants were used. The postoperative views are with a final volume of 600 mL after expansion to 750 mL for 6 weeks. |
 | Media file 6: A 28-year-old woman with slight breast asymmetry (right larger than left). Currently an AA cup, she requested a C/D cup. The estimated total volume is 650 mL, with more required on the left side. The 575+-mL Spectrum implants were used and filled to 720 mL in the right and 780 mL in the left. Final volume is 600 mL in the right and 660 in the left. |
 | Media file 7: A 35-year-old woman with A/AA breasts requested a mid-C cup. The preoperative estimate was 500-550 mL, and 475+-mL Spectrum implants were filled to a total of 650 mL for 6 weeks. Then, 120 mL was removed, for a final volume of 530 mL. |
 | Media file 8: A 30-year-old woman with 700-mL encapsulated implants in a subglandular position. Nipples are ptotic to 26 cm from the sternal notch. The tissue is paper thin because of implant position and attenuation from stretching. She refused to have a mastopexy because of her profession (exotic dancer). An exchange of pockets from subglandular to submuscular (without capsulectomy) was performed. The skin and nipple-areola complex were supported with tape dressings and a bra for approximately 3 weeks. A bilateral inferior capsulotomy was performed at the end of the procedure. The temporary total volume was 1000 mL, with a final volume of 850 mL. The implants were overfilled by 150 mL because the patient preferred the round look to the natural appearance. Note that the nipples have been elevated by scar contracture of the subglandular pocket from 26 cm to 23 cm. |
 | Media file 9: A 34-year-old woman with prior augmentation. The right implant capsule was too lateral and the left implant crossed over the midline. Also, a prior attempt had been made to medialize the left nipple. After bilateral internal capsulodesis, the expanders were filled to only 200 mL and were not expanded for 3 weeks to allow for healing of the repair. Expansion resumed after 3 weeks to round out the capsule and overcome adverse scarring. They were filled to 720 mL, and the final views are at 620 mL. |
 | Media file 10: A 32-year-old woman with prior augmentation using small implants. The right is subglandular, and the left is submuscular. The right nipple is 22 cm from the sternal notch, and the left is 21 cm from the sternal notch. An implant "knuckle" is visible in the right medial breast area. The plan was for a right Benelli lift and bilateral expansion (submuscular) to achieve volumetric and shape symmetry. Her prior implants were 175 mL and she wished to be a C cup. The breasts had a volumetric difference of approximately 75-100 mL. The 475+-mL Spectrum implants were chosen for both sides. The final views are at 4 months total. Both sides were filled to a total of 660 mL. The final volume is 510 mL on the right and 530 mL on the left. |
 | Media file 11: A 24-year-old woman with tuberous breast deformity and marked tissue deficiency on the left side. She wanted a full C cup. The 375- to 450-mL Spectrum implants were chosen. The patient was forewarned to expect an inframammary dent. The tissue deficiency of the lower pole of the left breast is very evident at 2 weeks. However, with continued stretching, the deficit is minimized visually to a great degree. The total fill volume was 700 mL for 8 weeks, and the final volume was 520 mL after release of 180 mL. |
 | Media file 12: A 29-year-old woman with A cup and pseudoptosis wanted full C cup and upper pole fullness. The size estimate was approximately 400 mL total (perhaps more for upper pole fullness). The 375+-mL Spectrum implants were chosen. The total fill was to 570 mL for 6 weeks, with removal of 180 mL to a final volume of 390 mL. |
 | Media file 13: The final pictures are of a 27-year-old woman who had a prior breast augmentation with 450-mL implants. She requested an E or F cup from a D/DD. The increase in size requested was probably only 300 mL, so 475- to 570-mL Spectrum implants were used. The total fill was to 1250 mL, and the final volume was 1130 mL. |
 | Media file 14: This 42-year-old woman has postpartum atrophy and ptosis. She is 5 ft 4 in tall and weighs 158 lb. She wished to be enlarged from a B to a C cup with a breast lift. This was accomplished with a vertical mastopexy, removing approximately100 grams of breast tissue from each side. Because there is approximately 200 g of breast tissue per cup size, this would leave her with 300 g of breast tissue per side. A C cup requires 600 mL of total volume (assume g = mL), so she would need approximately a 300-mL increase. The 325- to 390-mL Spectrum implants were used, and the final fill volume the patient requested was 360 mL. The views shown are 3 years postoperative. |
 | Media file 15: This 26-year-old woman lost 150 pounds after gastric bypass surgery 7 years ago. She is shown at 140 lb, 5 ft 5 in tall, and measures an A cup (200 g). She wished to be lifted and enlarged to a C cup. A Weiss pattern reduction was performed, removing approximately 100 g per side, and 475- to 570-mL Spectrum implants were used. (A 100-g reduction from her 200 g leaves 100 g. A full C cup requires 600 mL of total volume). The views shown are 8 months postoperative. |
 | Media file 16: This 48-year-old woman has significant ptosis with the distance from sternal notch to nipple of 26 cm on the R and 27 cm on the left. Her bra size measured a 36 D/DD, shown in preoperative photos on the left. She requested a breast reduction (lift) to end up as a C/D cup, which would require a net reduction of two cups or about 400 g of breast tissue. Because of the preoperative discoid shape, an implant was considered necessary to give a rounder appearance to the breasts. It was decided to use a 325+ mL Spectrum implant, so an additional 300 grams needed to be removed in order to compensate for the implant size. The photos on the right are postoperative views at 3.5 years. |
 | Media file 17: This patient in this series of photos is 31 years old, nulliparous and was 5'8", 135# and measured as a 34 A+ cup bra. She wished to be increased to a C/D cup. Her preoperative measurements showed the nipple to be 20 cm from the sternal notch on both sides, with no asymmetry. She required a 1-2 cup increase (200-400 mL), so a 375-450 mL Spectrum was chosen. At surgery, the implants were placed totally submuscular, filled to 300 mL, and then filled to a temporary overfilled volume of 600 mL. After 6 weeks, the excess saline was removed to a final volume of 450 mL. The photos on the left are preoperative views. The center photos are postoperative views, with implants overfilled to 650 mL bilaterally. The photos on the right are postoperative views at 4 years, with final volume of 450 mL. |
Keywords
breast implants, silicone implants, saline implants, adjustable implant, breast expander, breast expansion, breast expansion-augmentation, postoperative adjustable implant, adjustable breast implant, Becker expander, Spectrum implant, saline expander, Becker valve, fill tube, reservoir system, gel/saline Becker expander, Spectrum saline implant, breast augmentation, adjustable breast augmentation, breast enlargement, adjustable breast enlargement
More on Uses of the Postoperatively Adjustable Implant in Aesthetic Breast Surgery |
| References |
References
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Further Reading
Keywords
breast implants, silicone implants, saline implants, adjustable implant, breast expander, breast expansion, breast expansion-augmentation, postoperative adjustable implant, adjustable breast implant, Becker expander, Spectrum implant, saline expander, Becker valve, fill tube, reservoir system, gel/saline Becker expander, Spectrum saline implant, breast augmentation, adjustable breast augmentation, breast enlargement, adjustable breast enlargement
