Achieving the Breast Job for Patients

Breast augmentation

Dr Alan Breidahl, ASAPS Member and Specialist Plastic Surgeon from Melbourne Plastic Surgery said there are five indicators for whether or not you’ve achieved the ‘breast’ job for your patient:

  1. How they feel to the patient – Perfectly augmented breasts need to feel like normal breasts to the patient, as if there has been no surgery performed.  In particular, the patient should have virtually invisible scars, no pain or lumps, with the implants soft and unable to be felt, blending imperceptibly with the natural breast.  The implants should also move in synergy with the breast, and should not be stuck rigidly to the chest wall or independently of the rest of the breast with muscle action.
  2. How they look – Perfectly augmented breasts should look symmetrical (within the bounds of normal variation), there should be no obvious scars when naked, in a bikini or a strapless dress, they should be age appropriately pert, and there should be one ‘breast mass’ on each side (not two, which would indicate an implant and original breast).  The implant should also change their appearance as a natural breast does by hanging to a degree when naked, with minimal upper pole fullness (minimum volume sitting high above the nipple), yet being able to produce upper pole fullness naturally in a push-up bra, but without displaying any ridges.
  3. How they feel to your partner – Perfectly augmented breasts feel like normal breasts, and even a trained hand may have difficulty identifying whether or not someone has implants.
  4. They should be stable over time (in other words their appearance and feel should not change with the passing of the years).
  5. Perhaps most importantly, they need to be safe.

A surgeon can achieve the perfect breast augmentation for patients as follows:

General surgical technique

General surgical technique includes operating in an accredited facility which is regularly audited for things such as infection control (read more about the 14-Point-Plan which is designed to minimise the number of bacteria that can contaminate breast implants at the time of surgery and reduce the risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)).

Operating with care and being as gentle as possible with the surrounding breast tissues also helps to minimise damage to your skin, subcutaneous tissues, muscle and breast.  Operating carefully reduces external and internal scarring, lessens the risk of infection (as bacteria can breed in damaged tissues) and capsular contracture (hardening of an implant resulting from the contraction of scar tissue surrounding the implant).  Careful sealing of any bleeding blood vessels with diathermy also minimises the risk of a haematoma, which can lead to infection and capsular contracture.

Type of incision

There are several choices for the incision but in my opinion only one good one.  The incision I prefer is in the infra-mammary crease, which is the fold immediately below the breast, where it meets the chest wall. If the scar ends up in the inframammary crease, then it is nearly always virtually invisible.  The surgeon will have the best access to the breast implant pocket through an infra-mammary incision and therefore has a much higher chance of achieving symmetry with minimal trauma and excellent control of bleeding.  The infra-mammary incision also avoids cutting through any breast tissue, which minimises the risk of infection and protects all of the breast tissue for any future breastfeeding.  Another advantage is that the surgeon can preserve the join of the anterior and posterior breast capsules with Scarpa’s fascia; essential to maintaining a natural infra-mammary fold (the breast gland is contained in a capsule of fibrous connective tissue, which is a splitting of the superficial fascia in the subcutaneous layer, called Scarpa’s fascia.

Incisions around the nipple-areola are more likely to be seen naked, even if it is just by the patient in the bathroom after a shower.  These incisions also involve cutting through breast tissue, which may decrease the chances of future breastfeeding and increase the risk of infection and capsular contracture and BIA-ALCL.  The 14 point plan recommends avoiding this incision.

Incisions in the armpit can be virtually invisible but not always and if there is any problem with scarring these incisions can be quite visible.  They are also a long way from the infra-mammary fold, making it difficult to achieve symmetry using a minimally traumatic technique. Armpits are also full of sweat glands that carry more bacteria than normal skin so the risk of infection (and subsequent BIA-ALCL) may be higher.

Type of implant

First is the saline versus silicone fill question.  In my opinion saline implants feel and behave like a bag of water; I can always feel saline implants, and thus I can never achieve the ‘perfect breast augmentation’ with them.

To my mind, there is only one type of silicone implant that should be used – smooth round silicone gel implants.  The most important reason for this is that they are currently the only type of silicone implants that have been in use long enough to demonstrate they are not associated with BIA-ALCL.  Even before this disease was identified, I routinely used smooth implants because they are soft, difficult to feel (when capsular contracture has occurred), do not stick to the chest wall and are therefore mobile and move like natural breasts.  I can always feel textured implants because they are harder with thicker envelopes than smooth implants and it’s for this reason that I can’t achieve the ‘perfect breast augmentation’ with textured implants.

All smooth implants are round, but because the silicone flows more easily within them, they adopt a ‘teardrop’ shape when standing, but then lose it when lying down.  By contrast, ’teardrop’ shaped implants retain their shape when lying down and to my eye, this makes them more visible when lying on the beach or in bed.  Further, all teardrop implants are textured, meaning they carry the risk of BIA-ALCL.

Pocket position

The best outcome is one where the implant is one with your normal breast tissue.  The pocket position is a critical factor to achieving this.  The pocket should be on top of Pectoralis muscle and the implant placed directly behind the breast capsule so that the implant and breast becomes a single unit, and moves as such.  As soon as an implant is put underneath the muscle it becomes challenging to have the breast and the implant act as a single unit.  When under the muscle, the breast and implant are more likely to appear as two separate mounds, with the natural breast moving (and sometimes drooping) separately to the implant. With the implant under the muscle, it can appear unnatural because the implant often becomes more rigidly fixed to the chest wall and doesn’t move.  Alternatively, the implant can attach to the pectoralis muscle itself and move with any muscle action, which also appears unnatural.

The only problem with this is the increased risk of capsular contracture of a smooth implant when placed above the muscle.  This is what stops surgeons from being able to achieve the ‘perfect breast augmentation’ every time.  However recent studies suggest that this increased risk may relate to increased bacterial contamination from the breast tissue, so if the surgeon can maintain the integrity of the posterior breast capsule with minimal trauma, then the risk of capsular contracture should be minimised.  This is what surgeons are attempting to do with the ‘sub-fascial’ approach.  In any case, the vast majority of patients do not develop significant capsular contracture when the implants are placed in front of the muscle and on this basis, I prefer to place the implants in front of the muscle when aiming for the ‘perfect breast augmentation’.

Pocket size

Pocket size is critical, no matter where the implant is placed.  If the pocket size is too small, the implants will be rounded, high and hard, as if they have a capsular contracture from the start.  If it is too large, then the implants may fall out into the armpits, lack adequate cleavage or appear to join together in the mid-line (symmastia).

Post-operative care

Good post-operative care is vital.  Avoiding strenuous activity for three weeks is critical to minimise the risk of bleeding and wound healing complications which might lead to infection, scarring, capsular contracture and perhaps BIA-ALCL.  Wearing a supportive bra for the first six weeks also helps keep the implants in the correct position while healing.  If advised (particularly with smooth implants in front of the muscle), a program of regular self-massage can minimise the risk of capsular contracture.

Sadly, other surgeons nor I can achieve the ‘perfect breast augment’ result in every patient.  What I have described is my technique which I believe achieves the best possible outcome in the vast majority of my patients.  The main issue that this technique presents in a percentage of patients is capsular contracture.  Many surgeons do not use this technique because of this fear, however, I think that this approach is giving up on the idea of the ‘perfect breast augmentation’ before the operation is even scheduled.  Even by using textured implants and placing the implants under the muscle there is still a considerable risk of capsular contracture as well as extra problems, such as the risk of BIA -ALCL, the implant being separate to the breast, moving unnaturally with the muscle or being rigidly fixed to the chest wall.



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