Subglandular Breast Augmentation Treatment & Management

Despite occasional false advertising to the contrary, no drug enlarges a female breast permanently.

However, a device that stretches the skin externally is purported to cause proliferation of the underlying tissue to provide an increase of up to one cup size. It currently is undergoing testing as to its efficacy and the permanence of the result. Thus far, the device has not proved to be very well accepted.

In the author's opinion, micromastia is best treated with a subglandular breast augmentation.

Thoroughly discuss the procedure and its risks with the patient during the preoperative consultation. Especially assess the patient's personality and expectations.

• Inform the patient of details of what to expect before, during, and after the surgery.

• Attempting to meet the patient's expectations regarding size is very important. When a patient asks for an implant that the author feels is too large, he explains why he believes that the implant would be deforming and informs the patient that he will place the largest implant that appears natural.

• In situations in which flexibility is possible and the author is not sure exactly what the patient wants, patients are asked to bring in a picture from a magazine or lingerie catalogue to provide an idea of what they envision for themselves.

• Aspirin and ibuprofen should be avoided for 2 weeks before surgery.

If the operation is performed by means of the inframammary route (author's preference), the incision need only be 2.5-3 cm if an inflatable implant is used.

• Mark the incision preoperatively with the patient in the upright position. Place the incision in the inframammary fold, lateral to the midmammary line. The author makes no other preoperative markings, relying on judgment during the operation regarding size and placement. Postoperatively, the expansion of the skin brings the incision up on the undersurface of the breast for a distance of 1-2 cm. This keeps the scar from being visible in a bikini bathing suit. The resulting scar is almost always acceptable and revision is rarely necessary.

• Carry the incision down through subcutaneous tissue and superficial fascia onto the fascia of the serratus anterior muscle. Continue dissection superiorly over the fascia of the pectoralis major muscle to a level of approximately the second rib, as a large pocket is essential. This can be accomplished with scissors in combination with finger dissection, spreading devices, or a sponge on a stick.

• Do not carry the medial dissection further than the lateral sternal border. An attempt to give the patient cleavage by dissecting further medially results in symmastia, an unsightly bridge of skin joining the breasts together that is also termed a unibreast.

• The lateral extent of the pocket is a matter of judgment. The author usually makes a modest dissection to the anterior axillary line, and after the implant is in place, the finger is used to extend the lateral dissection until the outline of the implant is no longer apparent.

• Meticulous hemostasis using electrocautery is absolutely essential. The author uses a fibro-optic lighted retractor for visualization. Usually the dissection is performed on one side, a few sponges are placed in the pocket, and then the other side is dissected. When returning to the first side, small bleeders occasionally are apparent and can be cauterized.

• Once the pocket is dissected and hemostasis is assured, the author first places an inflatable sizer corresponding to the projected size of the implant. After filling it with air, the judgment is made regarding which size best fits the patient and addresses her expectations.

• Then place the implant in the pocket and inflate it with saline. Adding anything to the saline is advised against strongly. Betadine is suspected to weaken the implant wall, and steroids are well known to cause erosion of the overlying tissue, resulting in exposure and extrusion of the implant.

• The author recommends filling the implant to the maximum amount allowed by the manufacturer. The author occasionally adds an additional 5-15 mL more than that amount, depending on the size of the implant, in the belief that this helps prevent rippling of the implant. However, if too much saline is added, scalloping of the implant edges results, which will appear as rippling.

• The author prefers smooth-walled, round implants. Textured implants have thicker shells; thus, any rippling becomes much more offensive. The author also has experienced a higher incidence of capsular contracture with textured implants and serious leakage problems with textured saline implants. Round implants are used because oval or teardrop-shaped implants that are not textured can rotate.

• Close the incision in layers. Suture the superficial fascia with absorbable sutures such as Dexon or Vicryl. The author also places interrupted subcuticular sutures that are absorbable and closes the skin with 6-0 nylon. Some surgeons prefer a continuous subcuticular closure. The bandage merely covers the incision, and the author employs no other taping.

The author uses postoperative antibiotics and prescribes a mild opioid analgesic and acetaminophen for pain. Aspirin and ibuprofen should be avoided for 2 weeks after surgery. Vitamin E, zafirlukast (Accolate), and echinacea are prescribed for possible prophylaxis against capsular contracture, although the evidence that they help is only anecdotal. Thus far, reports of success with these medications are anecdotal.

Remove sutures after 1 week.

Although the author does not require the patient to wear a bra in the first postoperative week, he has no objection to its use immediately after surgery. After the first postoperative week, a sports bra often makes the patient more comfortable for the next month.

Advise the patient to refrain from physical exercise for 3 weeks; the patient can return to work in approximately 3 days (vs 1-2 wk with submuscular augmentation). Patients are otherwise allowed to engage in whatever activities they feel comfortable doing.

Patients are seen 1, 2, and 6 weeks postoperatively. Although patients are instructed to massage their breasts after the second week, the author believes that this is of limited value, if any.

Patients usually return on their own if they experience a capsular contracture, which can be treated with closed capsulotomy.

The prospective patient must be informed of the risks and possible complications of the operation.

Infection

Infection is a rare complication, which occurs, in the author's personal experience, in approximately 1 patient per 1000. It usually necessitates removal of the implant and replacement at a future date. ^[5]

Postoperative bleeding

This occurs in 0.5-1% of patients. While it is not life threatening, it requires additional surgery to stop the bleeding.

Deflation

Several years ago, the author used textured saline implants in approximately 100 patients, and deflation resulted in 5 patients, which is highly unacceptable. In approximately 1600 patients in whom the author used smooth-walled saline implants, only one deflation had occurred at the time of this writing. However, deflation is certainly a known risk and could well happen due to fold faults, which are continuous flexing of the implant edge that, like repeated bending of a paper clip, can cause failure of the implant. Rarely, the filling valve can be defective.

Capsular contracture

Capsular contracture is the major problem with breast implants. If the capsule contracts around the implant, it squeezes it and makes it feel hard. This complication can be treated with closed capsulotomy but it may recur.

Many studies demonstrate no difference in contracture rates when the implant is over or under the muscle. However, a review study by Egeberg and Sørensen suggested that subglandular breast augmentation carries more than twice the risk of capsular contracture that the submuscular technique does. Results were derived from a meta-analysis of 10 studies, involving a total of 17,520 breast implants. ^[1]

Vitamin E and zafirlukast (Accolate) are believed by some to reduce the incidence of capsular contracture. The author's incidence of capsular contracture with 2500 subglandular augmentations is between 5% and 7%. ^{[5, 6]}

Rippling of the implant

Although this occurs more frequently in patients who have thin breast tissue following pregnancy or who have deep stretch marks, it can occur in any patient. Silicone implants have a much lower incidence of rippling because the gel adheres to the elastomer lining, which helps to keep it from rippling. Hydrogel, where available, also results in less rippling. ^[5]

Atrophy

A study by Weck Roxo et al found that at 12-month postoperative follow-up, women who underwent subglandular breast augmentation (24 patients) demonstrated significant atrophy of the breast parenchyma. In contrast, women who underwent submuscular breast augmentation (24 patients) demonstrated significant atrophy of the pectoralis major muscle. ^[7]

Subpectoral repositioning

A retrospective study by Hauch et al reported that the investigators’ technique for subpectoral repositioning of subglandular implants can be successfully performed on patients who present with complications of implant surgery years after subglandular augmentation. The patients, who presented a mean 18 years after their initial operation, had experienced “slide-down” deformity, along with complications such as capsular contracture, implant wrinkling, and enlarged areolas. Instead of using an acellular dermal matrix (ADM) or a mesh, the procedure, employing a partial capsulectomy, retained the inferior and posterior sections of the capsule to serve in place of the ADM or mesh. This ensured that the implant was adequately covered and avoided window shading of the pectoralis major muscle. Twenty-four patients were included in the study, of which, at average 3.1-year follow-up, two individuals underwent minor revisions under local anesthesia, with two more revisions (to correct malposition in one patient and to insert larger implants in the other) performed under general anesthesia. ^[8]

The implant manufacturers state that their products are not meant to be lifetime devices, but because of their long-term guarantees of replacement, they obviously hope that they will be used over the patient's life.

Overall, the author has found a high degree of patient satisfaction with subglandular placement of breast implants and recommends that approach. Whatever the complications with hardness or rippling, almost no one asks for the removal of the implants.

Results are shown in the images below.

A literature review by Azzi et al indicated that in women who develop breast cancer subsequent to breast augmentation, patient prognosis is not linked to implant location. Among breast cancer patients in the study, 26.5% of women with subglandular implants had tumors 2-5 cm in size, compared with 9.9% of women with subpectoral implants; the frequency of stage 2 tumors also varied (42.9% vs 23.7%, respectively). According to the investigators, these results suggest that radiologic detection of early tumors is delayed by increased distortion from subglandular implants. However, the study also found that lymphovascular invasion, as well as the frequency of tumors over 5 cm in size or that were diagnosed as stage 3, did not differ significantly between subglandular and subpectoral implant patients. ^[9]