Women seek cosmetic breast surgery for a variety of reasons, the most common of which are the desire to enhance or reduce overall breast size and the wish to reshape (lift) the breast. While cosmetic surgeries described here can produce empowering changes for properly selected patients, it must never be forgotten that the overall health of the woman and her breasts is of paramount importance, and that care must be exercised to see that cosmetic surgery does not impact wellness in a negative way.

Discussions of breast augmentation, can be viewed by choosing from among the panels immediately below. Breast lift and reduction can be explored via the "Detail" links to the right. Also presented is expanded information on breast implants and materials devoted to other important breast topics.

It has long been a desire of many women to increase the fullness or volume of the breasts. Genetically small breast size or involution of the breast after pregnancy can leave a woman with a distressing imbalance in her figure, affecting her self-image and making clothing choices difficult. Surgical breast augmentation was once available only to the wealthy and famous, but today procedures have become both widely available and more safe. As a result, breast enlargement is now one of the most commonly sought after cosmetic surgical procedures. However, breast enhancement will produce some permanent changes to a woman's body about which she should be instructed before making any decision for surgery.

Implants

Volumetric augmentation is accomplished by the placement of "implants" behind the breasts. The implants currently used for breast enhancement are made from very pure silicone that is chemically identical to that used in many other implantable medical devices including artificial joints and neurological shunts. It is well tolerated within the body in the great majority of cases. (Learn details about implants.) As with all procedures involving the use of artificial materials, breast augmentation does have potential complications. However, these occurrences are infrequent and most often amenable to treatment.

The Surgery

A small incision is made on or near each breast through which the surgeon can create a space for the implant. The access types most commonly employed include the crease beneath the breast, (so-called "infra-mammary" incision), the edge of the pigmented circle around the nipple, ( the "peri-areolar" incision), or the armpit, ("axillary" incision). Some doctors have a favored approach, while others may use any of these depending upon the circumstance. Most would agree that the infra-mammary and peri-areolar approaches suffer from fewer clinical limitations than the trans-axillary approach, which cannot be used to optimal effect in certain breast types. In any event, prospective patients should discuss the relative merits of each approach with their doctors before a final treatment plan is arrived upon. Some widely agreed-to advantages and disadvantages of each include:

Inframammary

Advantages

• Best overall access
• Useful in any breast type
• Any implant type or pocket position possible
• Easiest to extend when necessary
• Best route for re-operation in future
• Less visible than peri-areolar when naked

Disadvantages

• Visible scar beneath breast
• Potentially visible when recumbent wearing "high-riding" bikini

Peri-areolar

Advantages

• Good overall access
• Useful in any breast type
• Easily incorporated into mastopexy incision for those who need lift
• Any implant type or pocket position possible
• Usually acceptable route for re-operation in future
• Only visible when breast completely naked

Disadvantages

• Visible scar when nipple uncovered
• Extension of incision not possible
• Poor choice when circumference of areola is small
• Slightly higher rate of nipple sensation changes (compared to infra-mammary)
• Slightly higher infection rate? (compared to infra-mammary)

Axillary

Advantages

• No scar on breast
• May allow more rapid, "office" surgery

Disadvantages

• Scar visible to non-intimates when arm raised
• Gives surgeon less overall control
• Submuscular-only placement
• Orientation of anatomical implants more difficult
• Poor choice when breast is slightly ptotic (droopy)
• Cannot be incorporated into combined mastopexy procedure
• May need separate incision for future re-operation

The "Pocket"

Once access has been gained, a space called a "pocket" must be developed to be home for the implant. Early in the history of this surgery, this pocket was always designed directly beneath the breast, (so-called "subglandular" pocket). This, of course, made intuitive sense, since the purpose of the procedure was to magnify the breast. However, because of the high incidence of breast hardening ("capsular contracture") during the early years, doctors began to experiment with different approaches, one of which was to lift chest wall muscle as a part of pocket creation, ("sub-muscular" or "sub-pectoral" pocket). While data from that time suggested that hardening was less common when the pocket was made beneath muscle, it is not totally clear that pocket position makes as much of a difference to contracture rates with today's implants.

Many good surgeons prefer subglandular placement, while others choose submuscular. Some will choose one or the other based upon the individual clinical situation. As with incision choice, the patient should discuss options for pocket placement to learn about the advantages and disadvantages of each.

Sub-glandular

Advantages

• Less post-operative pain and somewhat shorter recovery
• Better shaping of slightly ptotic (droopy) breast
• No post-op distortion of breast shape with sustained muscle activity
• No damage to chest muscle
• Future explantation for implant failure easier

Disadvantages

• Less cover for upper pole of implant in very thin
• ? Slightly higher rate of capsular contracture
• Upper pole "ripples" more likely when saline implant used
• ? More difficult mammography

Sub-muscular

Advantages

• More cover for upper pole of implant in very thin patient
• Upper pole "ripples" less likely when saline implant used
• ? Slightly lower rate of capsular contracture
• ? Less difficult mammography

Disadvantages

• Higher implant rupture rate
• More post-operative pain and somewhat longer recovery
• Post-op distortion of breast shape with sustained muscle activity
• Atrophy of cut portion of chest muscle
• Poor shaping of slightly ptotic (droopy) breast
• Future explantation for implant failure more difficult

More critical to the cosmetic quality of the outcome than the type of implant chosen, or the incision and pocket type, is the use of an implant whose shape and volume take fully into account the individual anatomy of the patient.
It is a common misconception that a breast of equal beauty can be made at any size. A patient whose tissues will allow a beautiful and natural enhancement of one cup size may look un-natural and distorted following a two cup size enlargement. Also, "over augmentation" can lead over time to thinning of tissues and breast distortions that become cosmetic problems that are difficult, or even impossible, to fix.

For most patients who choose surgery, a soft, natural enlargement of the breasts is accomplished and maintained for many years. (See photo examples of breast augmentations. ) Surveys have shown that the great majority of women remain pleased with their choice for surgery 8-10 years later. However, each woman should be aware before surgery that removal or exchange of implants may be needed in the future if hardening or deflation occur. Also, prior to making any decision for surgery, prospective patients should contemplate the side effects, limitations and risks of this operation.

Side Effects

• Permanent scars (every patient)
• Loss of nipple sensitivity (some patients)

Limitations

• Implants are palpable (can be felt when the breast is touched)
• Imperfect symmetry
• Implants have a finite lifetime
• Implants make imaging of the breast more complex

Risks

• Post-operative bleeding (hematoma)
• Wound infection (with possible implant loss)
• Capsular contracture (hardening of the breast)
• Early implant failure (rupture)
• Breast calcifications

If a patient desires the removal of her implants at any future time, this can be accomplished through further surgery. Because of the changes brought by aging and the influence of the implants themselves, no precise predictions can be made about breast shape after implant removal. While many women will enjoy what they find to be an acceptable (albeit less appealing) shape, others may feel the need for breast reshaping via mastopexy.

The original, alloplastic breast augmentations were performed in the early 1960's and employed devices made from silicone elastomer filled with silicone gel. Dow Corning and the surgeons who originated this procedure chose gel as the filler because of its ability to simulate the feel of breast fat, (hence the description, "natural-feel prosthesis"). High rates of capsular contracture (see below) led to more experimentation with implant fillers, and the appeal of saline was hard to resist. Because it is a truly physiological material, saline was readily embraced by some, and for what proved to be a real diminution of contractures, it was doubly welcomed. High leakage rates and the less natural "feel" of these salt water devices continued to make them the choice of a minority of surgeons and their patients, however.

In 1992, the FDA placed a moratorium on the use of gel implants in the United States. This was done in reaction to public concerns (fueled by tabloid stories and TV shows) suggesting that breast implants might promote disease. Despite the fact that European and South American scientific groups and governmental regulators saw no reason to restrict implant usage, the U.S. FDA Commissioner over-ruled his own scientific advisory board and placed limits on gel implant usage. As a result of this restriction, implant manufacturers re-doubled their efforts to generate the data needed to satisfy FDA with regard to the safety and efficacy of gel implants. At the same time, they also devoted themselves to further improvement of the saline devices that American physicians would be required to use.

Between 1992 and 2007, primary breast augmentation on women of normal anatomy was carried out exclusively with saline prostheses. This allowed both surgeons and patients to assess first-hand what is good and bad about the devices.

What's Good about Saline?

• Filler is physiologic, so leakage is harmless
• Saline is absorbed with leak, so diagnosis of failure is easily made
• Capsular contracture rate is less (? not certain)

What's Not Good about Saline?

• More frequent leakage
• Less natural "feel"
• More subject to visible surface irregularities (ripples / wrinkles)

As of 2007, FDA reversed its previous restriction on the general use of gel-filled breast implants. The devices that are now available employ new, highly cohesive gels that maintain shape even when the envelope is breached, ( "memory gel"). While this new filler is not a physiologic substance like saline, it has its own set of advantages and disadvantages.

What's Good about Gel?

• Leakage rate is likely lower than saline
• More natural "feel"
• Not prone to surface irregularities (ripples / wrinkles)

What's Not Good about Gel?

• Non-physiological filler
• Higher capsular contracture rate (? uncertain with modern devices)

In the final analysis, patients should discuss the implant options in detail with their plastic surgeons. The advantages (and downsides) of each must be considered in order that every patient be empowered to make the best decision regarding which to choose. The following links are provided as sources of potentially useful information.

Silicone Safety- Mentor

Silicone Safety- Allergan

Breast Implant Safety

When any foreign object is surgically placed within the body, a "foreign body" reaction takes place. If the body is unable to "digest" the material, it will wall it off by building scar around it. The scar that forms around a breast implant is referred to as a "capsule," and it is a universal and normal sequelum of surgery.

When the capsular scar is thin and remains "loose" around the implant, all is well with the breast. Because the implant can easily deform in shape when pressed upon, the breast feels soft. However, there are instances in which the capsule may tighten around the device, confining it and making it less deformable. When this occurs, a condition referred to as "capsular contracture" is said to exist. Contracted scar capsules are, in general, thicker and less compliant than others, and over time may even become calcified. However, it is important to understand that in the most typical scenario of contracture, it is not the implant or the scar itself that has become hard, but rather, it is the confinement of the implant and its inability to change shape when pressed upon that makes the breast feel hard.

Contracture can occur bilaterally, but as often as not, is seen on only one side. This fact reinforces the notion that it is more a "wound-related" phenomenon than a "patient-related" one. The initial relationship established between the soft tissues and the implant surface appears to be critical to the achievement of a soft result. Although the risk of capsular contracture continues to slowly rise over the lifetime of the augmentation, patients who develop more notable contractures often show signs of it in the early months after surgery.

The firmness created by capsular contracture may range from very mild to rigid, woody-feeling hardness that is accompanied by discomfort and spherical distortion of breast shape. (The "too-round" look of many augmented breasts seen in the tabloids and magazines is generally the result of either capsular contracture or "over-augmentation.") The most convenient and widely used clinical measure of contracture is called the Baker scale:

• Baker 1- Soft breast with natural feel and shape
• Baker 2- Implant palpable, breast less soft but undistorted in shape
• Baker 3- Breast firm with some visible shape distortion
• Baker 4- Hard, painful, spherically-distorted breast

Incidence

In the early years of breast augmentation, capsular contracture was quite prevalent and was the most common reason for a patient to need re-operation. Some estimate that more than 80% of patients suffered contracture in the 1960's. The years have brought changes in implant technology and in surgical technique, both of which have likely contributed to a steady fall in the incidence of this problem. The texturing of implant surfaces (first with polyurethane foam, and more recently with texturing of the silicone itself), is thought by some to contribute to the decline in contracture experience. However, studies that seem to indicate this are small and short term in nature. Also, the overall incidence of contracture has fallen enough to make it difficult to determine if there truly is a difference between smooth and textured devices with respect to hardening.

Collecting data to evaluate rates of contracture has been difficult, largely because implant technology has continued to evolve. This has made long term follow up on any large patient group with similar implants hard to accomplish. However, shorter term studies of currently used implants appear to confirm that much progress has been made in this area. While some studies show severe contracture rates in up to 8% of cases within the first few years, other studies put the rate at significantly less than 5%.

The decline in contracture rates also relates to improvements in surgical technique. Consensus suggests the following to be important:

• Use of direct vision surgical techniques with meticulous hemostasis
• Minimizing implant handling to avoid contamination
• Use of longer incisions to minimize implant contact with skin organisms
• Use of antibiotic irrigations of pocket

Causes

The causes of capsular contracture are not fully understood, and are likely multiple. Experience would suggest that bacterial contamination of the wound with the production of a sub-clinical "infection" may be in play, and the presence of more than a trivial amount of blood in the pockets also appears to be a factor. Hence, the above-mentioned efforts by surgeons to minimize implant skin contact and to make surgery as bloodless as possible.

Poor implant choice with "over-augmentation" of the breast may be a factor in some instances. Also, contamination of wounds with foreign substances such as talc from powdered surgical gloves has been shown to have statistical correlation to contracture experience.

Prevention and Treatment

Many plastic surgeons over the years have encouraged patients to "massage" their implants in the hopes of lessening contracture. While this is still practiced by some today, no studies of this method provide any indication of efficacy. As blood in the capsule seems to be a clear factor in contracture, patients can presumably help to prevent contractures by avoiding strenuous activities that might start bleeding during the early recovery period. There is also some data suggesting that the use of non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen may reduce inflammation and scarring if used during the early weeks after surgery.

Treatment for established contracture involves disruption of removal of the offending scar. "Capsulotomy," or splitting of the scar, immediately relieves the constriction, but is followed by recurrence a significant percentage of the time. In an effort to avoid surgery, some have championed the use of what is called "closed capsulotomy" in which the surgeon manually squeezes the breast until the capsule cracks. Since this involves risk for injury to the patient's breast as well as to the implant itself, most surgeons do not advocate its use, (and the implant manufacturers condemn its use). "Open" capsulotomy is a surgical procedure that requires the surgeon to re-open the incision and surgical cut the capsule to release it. While this is more precise and less risky that the closed procedure, the rate of lasting improvement is also disappointing.

"Capsulectomy," (surgical removal of the scar capsule), provides the greatest chance for sustained success in the search for softness. Capsule removal allows the body to form a completely new relationship with the surface of the implant, and this lowers chances for re-contracture to about the same levels as the initial contracture risk. Capsulectomy is not minor surgery, however, and the risks for bleeding, thinning of breast tissue and potential distortion of the breast contour must be fully considered.

Non-surgical treatments that have been reported, but for which data are scarce include external ultrasound and pulsed electromagnetic energy. Interesting preliminary data suggest that off-label use of Accolate (zafirlukast) and Singulair (montelukast), leukotriene pathway inhibitors used for treatment of asthma, may provide benefit in up to 25% of patients with established severe contracture.

 

Breast implants cannot be considered lifelong devices. Although the majority of implants remain intact for many years (and sometimes decades), they will all eventually weaken and fail.

Since the types of implants have continually changed over time, long term studies on implant longevity have been difficult to carry out. The size and nature of studies performed to look into implant failure make conclusions potentially inaccurate. Some work has suggested that the median "survival" of older vintage gel implants may be about 16-17 years. Only shorter term data are available on the more modern devices in current use. Some European work on the issue suggests that about 95% of cohesive gel implants are intact at 5 years, while something just over 85% are intact at 10 years. Saline implants likely fail more frequently than silicone gel since the water provides less support to the shell, causing it to fold and eventually fatigue.

Causes

Gross rupture of a breast implant can occur as a result of trauma. This may be injury from an impact, or from compression during mammography or by the surgeon performing "close capsulotomy," (see above). However, the majority of implant failures undoubtedly occur as a result of shell fatigue as the device ages. The age of the implant is likely the single most important factor in its ultimate failure, and breasts that suffer from capsular contracture are more likely to see implant leakage than soft breasts. In recent years it has also been demonstrated that implantation surgical technique may well affect the longevity of the device. Excessive or rough handling of the implant and use of inadequate incisions may weaken the shell during insertion. This is one of the reasons that many, including implant manufacturers, do not support the insertion of implants though an umbilical incision, (so-called "TUBA, or trans-umbilical breast augmentation).

Another factor of note is the choice of implant pocket location. Although submuscular placement may be associated with a somewhat lower risk for capsular contracture, it is clear that this position increases failure rates, in some studies by as much as a factor of three. When saline implants are employed, both over-filling and under-filling can lead to earlier device failure.

Signs and Symptoms of Rupture

When saline implants fail, the diagnosis is straightforward. The saline is absorbed with some speed and the patient sees her breast "deflate." Occasional valve leaks may take weeks or even months to make themselves known, but the more usual "fold flaw" tears of the implant shell usually become obvious in hours to days.

Failure of a silicone gel device may be much less obvious, and data suggest that the majority of leaks fall into the category of "silent ruptures" and are unknown to the asymptomatic patient. Others, however, will experience some change in the breast that alerts her to a potential problem. Among these may be:

• Pain
• Burning
• Change in shape or consistency
• Appearance of volume loss
• New "knot" or mass in breast
• New swelling or numbness
• New onset capsular contracture

Diagnosis

A skilled plastic surgeon can often detect changes on palpation of the breast that suggest rupture. However, even the best physician can be fooled. It is particularly difficult to evaluate the integrity of implants in those with capsular contracture. Where history of trauma or changes in patient symptoms or physical findings occur, imaging of the breast is indicated.

Mammography occasionally reveals findings suggestive, or even diagnostic of implant rupture. However, as an implant screening method it is very insensitive. Ultrasound offers more sensitivity, is not terribly expensive to perform and is available in many locations. However, it's accuracy is very much operator-dependant. The "false-positive" and "false-negative" rates for ultrasound are therefore higher than is ideal.

MRI has emerged as the gold-standard for the evaluation of implant integrity. Although it is not a perfect study, it is very sensitive and extremely specific as well, making diagnosis of implant rupture, (where it exists) very likely, and misdiagnosis of rupture unusual.

Because MRI is a very sensitive technique for imaging the breast gland itself, and is unimpeded in its look at the breast tissue by the presence of breast implants, it is becoming a very powerful and important tool in the surveillance of women with breast implants. Use of this method is important in surveillance of the breast tissue, and is critical in the evaluation of a breast that is felt to harbor a ruptured implant. MRI can quickly distinguish between "intra-capsular" and "extra-capsular" implant failure.

If an implant loses integrity but the scar capsule around the device remains intact, intra-capsular rupture is said to exist. In this situation, gel is kept from entering the surrounding breast tissue, (as in the above image). Where tear has occurred in both the implant shell and the fibrous capsule, gel may enter the surrounding tissues.

Treatment

Most agree that when implant failure is diagnosed, the devices should be removed. This can be done through the original incision used for augmentation, assuming that either inframammary or peri-areolar access was employed. Empty saline implants can be exchanged for new ones (if the patient prefers) and the capsule need not be altered or removed if the patient had been enjoying a soft, healthy result prior to leakage.

For ruptured gel implants, it is usually recommended that the patient undergo "total capsulectomy," or surgical removal of the scar surrounding the device. This is done to facilitate as complete a removal of gel material as possible. However, in select cases where complete capsulectomy may leave the patient with inadequate soft tissue cover, the surgeon may recommend leaving the capsule alone.

Patients who wish to be re-augmented after gel implant failure will often be re-implanted at the same surgery. However, if capsulectomy has been performed, getting the new implants to stay in proper position within the large resultant space can be challenging. At times, surgeons may recommend that patients "stage" the procedure, first allowing all to heal before returning to perform a new, separate breast augmentation.