Breast Augmentation - Strax Talks About the Procedure and Complications
Strax Rejuvenation has completed thousands of breast augmentation and wants you to know what to consider. By educating yourself about breast surgery, you will become much more comfortable with the process, learn how to maximize satisfaction with your results, and maybe even reduce surgery costs! To begin, read about some of the different breast implant options as cited from Wikipedia’s page on Breast Implants (see Source at bottom of page). The information is very helpful and informative, even though it wasn’t written entirely by Strax. There are two general types of breast implant devices, defined by their filler material: saline, and silicone. The saline implant has an elastomer silicone shell filled with sterile saline solution; the silicone implant has an elastomer silicone shell filled with viscous silicone gel.
Saline Breast Implants
Breast-implant devices filled with saline solution (salt water) of biological concentration were first manufactured by the Laboratoires Arion Company, in France, and introduced for medical use in 1964. In the 1990s, saline implants were the most common breast-implant device used in the U.S., because of the U.S. Food and Drug Administration restricted the importation of silicone breast-implant devices rarely used in other countries. Good-to-excellent results might result, but, when compared to silicone gel implants; saline breast implants are likelier to cause cosmetic problems, such as rippling, wrinkling, and being noticeable to the eye and the touch. Particularly for women with very little breast tissue, and for post–mastectomy breast reconstruction patients, silicone gel implants are the superior device for breast augmentation and reconstruction.
Silicone Gel Breast Implants
Now in its fifth generation, silicone has become an acceptable and even preferred implant by many.
In 1961, the American plastic surgeons Thomas Cronin and Frank Gerow and the Dow Corning Corporation developed the first silicone breast prosthesis; the first augmentation mammoplasty was in 1962. Silicone-gel breast implants are described in five device generations, defined by common model-manufacturing techniques.
Since the mid–1990s, the Fifth generation of silicone breast implant is of a semi-solid gel that mostly eliminates filler leakage (silicone migration). Studies report low incidence rates of capsular contracture and of device-shell rupture, improved safety and efficacy greater than that of early-generation breast-implant devices.
Breast Augmentation Incision Types
Breast implant device emplacement is performed with five types of surgical incisions:
- Inframammary — an incision made below the breast, in the infra-mammary fold (IMF), which affords maximal access for precise dissection and placement of the breast implant devices. It is the preferred surgical technique for placing silicone-gel implants, because of the better exposure of the breast tissue-pectoralis muscle interface; yet, IMF implantation can produce thicker, slightly more visible surgical scars.
- Periareolar — an incision made along the areolar periphery (border), which provides an optimal approach when adjustments to the IMF position are required, or when a mastopexy (breast lift) is included to the primary mammoplasty procedure. In the periareolar emplacement method, the incision is around the medial-half (inferior half) of the areola’s circumference. Silicone-gel implants can be difficult to emplace with this incision, because of the short, five-centimeter length (~ 5.0 cm.) of the required access-incision. Aesthetically, because the scars are at the areola’s border (periphery), they usually are less visible than the IMF-incision scars of women with light-pigment areolae. The nerves to the nipple are no more likely to be injured with the periareolar incision approach than with other surgical approaches.
- Transaxillary — an incision made to the axilla (armpit), from which the dissection tunnels medially, thus allows emplacing the implants without producing visible scars upon the breast proper; yet is likelier to produce inferior asymmetry of the implant-device position. Therefore, surgical revision of transaxillary emplaced breast implants usually requires either an IMF incision or a periareolar incision.
- Transumbilical — a trans-umbilical breast augmentation (TUBA) is a less common implant-device insertion technique wherein the incision is at the naval and the dissection tunnels superiorly. This surgical approach enables emplacing the breast implants without producing visible scars upon the breast; but it makes appropriate dissection and device-emplacement more technically difficult. A TUBA procedure is performed bluntly — without the endoscope’s visual assistance — and is not appropriate for placing (pre-filled) silicone-gel implants, because of the great potential for damaging the elastomer silicone shell of the breast-implant device during its manual insertion through the short — two-centimeter (~2.0 cm.) — incision at the navel, and because pre-filled silicone-gel implants are incompressible, and cannot be inserted through so small an incision.
- Transabdominal — as in the TUBA procedure, in the transabdominoplasty breast augmentation (TABA), the breast implants are tunneled superiorly from the abdominal incision into bluntly dissected implant pockets, whilst the patient simultaneously undergoes an abdominoplasty.
Breast Implant Pocket Placement
- Subglandular — the breast implant is emplaced to the retromammary space, between the breast tissue and the pectoralis major muscle. This position closely approximates the plane of normal breast tissue, and affords the most aesthetic results; but, in patients with thin pectoral soft-tissue, the subglandular position is likelier to show the ripples and wrinkles of the underlying implant. Moreover, the capsular-contracture rate is slightly greater with the subglandular implantation approach.
- Subfascial — the breast implant is emplaced beneath the fascia of the pectoralis major muscle; this is a variant of the subglandular position. The technical benefits of the subfascial breast-implant pocket technique are debated; proponent surgeons report that the layer of fascial tissue provides greater implant coverage and better sustains its position.
- Subpectoral (dual plane) — the breast implant is emplaced beneath the pectoralis major muscle, after releasing the inferior muscular attachments, with or without partial dissection of the subglandular plane. Resultantly, the implant is partially beneath the pectoralis major muscle in the upper pole, while the implant’s lower pole is in the subglandular plane. This implantation technique achieves maximal coverage of the upper pole of the implant, whilst allowing the expansion of the implant’s lower pole; however, animation (movement) of the breast implants in the subpectoral plane can be excessive for some patients, a condition known as “animation deformity”.
- Submuscular — the breast implant is emplaced beneath the pectoralis major muscle, without releasing the inferior origin of the muscle proper. Total muscular coverage of the implant can be achieved by releasing the lateral muscles of the chest wall — either the serratus muscle or the pectoralis minor muscle, or both — and suturing it, or them, to the pectoralis major muscle. In breast reconstruction surgery, the submuscular implantation approach effects maximal coverage of the breast implants.
Post-Surgical Recovery
The surgical scars of a breast augmentation mammoplasty develop over a six-week period and fade within months. Depending upon the daily physical activity each woman might require, breast augmentation surgery patients usually resume their normal lives about one week post-operative. Women whose breast implants were emplaced beneath the chest muscles (submuscular placement) usually have a longer post–operative convalescence, and experience slightly more pain, because of the incisions done to the chest muscles during the augmentation mammoplasty. The patient usually does not exercise or engage in strenuous physical activities for about six weeks. During the initial recovery, the patient is encouraged to flex and move her arm to alleviate pain and discomfort; also available are analgesic medication catheters for alleviating pain. Moreover, significantly improved patient recovery has resulted from refined breast implant emplacement techniques, submuscular and subglandular, that allow 95 per cent of patients to return to full, normal life activities within 24 hours post-operative, without bandages, drains, pain pumps, catheters, special brassieres, or narcotic-strength pain medication.
Breast Augmentation Complications
The surgical emplacement of breast implants — whether for breast reconstruction or for aesthetic purpose — presents the same health risks common to surgery, such as adverse reaction to anesthesia, hematoma (post–operative bleeding), seroma (fluid accumulation), site breakdown (infection) — and especially breast pain, altered sensation, impeded breast-feeding, visible wrinkling, asymmetry, thinning of the breast tissue, and disruption of the natural plane between the breasts, aka “bread loafing” or symmastia. Specific treatments for the complications of indwelling breast implants — capsular contracture and capsular rupture — are periodic MRI monitoring and physical examinations. Furthermore, complications and re-operations related to the implantation surgery and to tissue expanders (implant place-holders during surgery) can cause unfavorable scarring in about 6%–7% of patients; and can increase medical costs.
Repair and Revision Surgeries
When the patient considers the outcome of an implantation mammoplasty unsatisfactory, or when technical or medical complications occur, or because of the breast implants’ limited product life (as a Class III medical device, in the U.S.), it is likely that women might have to replace their breast implants. The common re-operation (replacement) indications include major and minor complications, capsular contracture, shell rupture, and device deflation. Re-operation rates were greater for breast reconstruction patients, because of the post-mastectomy changes in the soft-tissue envelope and to the anatomical breast borders, especially in patients who received adjuvant XRT (external radiation therapy). Moreover, besides the reconstruction mammoplasty, breast cancer patients usually undergo surgeries of the nipple-areola complex (NAC), and symmetry procedures upon the opposite breast. Carefully matching the patient’s pectoral soft-tissue characteristics to the type and size of the breast implants reduces having to re-operate. With appropriate implant selection and proper implantation, the re-operation rate was 3% at the 7-year-mark, compared with the re-operation rate of 20% at the 3-year-mark, as reported by the U.S. Food and Drug Administration.
Breast Implant Rupture
Because a breast implant is a Class III medical device of limited product life, the principal rupture-rate factors are its age and design, although it can remain intact in a woman’s body for decades. The suspected rupture mechanisms are: damage during implantation, damage during (other) surgical procedures, the chemical degradation of the breast implants shell, blunt chest trauma, penetrating chest trauma, and, infrequently, the mechanical pressure common to traditional mammographic breast examination. When saline breast implants rupture, they usually quickly deflate, and thus are readily removed. Studies of women with saline implants reported 3-year-mark rupture-deflation rates of 3%–5% cent, and 10-year-mark rupture-deflation rates of 7%–10%. When a silicone-gel breast implant device ruptures it usually does not deflate, yet the silicone-gel filler can leak from the device to the implant pocket, wherein rests the breast implant proper. An intracapsular rupture (in-capsule leak) can progress to extracapsular rupture (out-of-capsule leak); each condition generally indicates surgical removal of the breast implant device. Although extracapsular silicone can migrate from the chest to elsewhere in the patient’s body, most such clinical complications were limited to the breast and axillae areas, manifested as granulomas (inflammatory nodules) and axillary lymphadenopathy (enlarged lymph glands in the armpit area).
From the long-term MRI data for single-lumen breast implants, the European literature about silicone-gel breast implants designed in the 1970s (Second generation), reported silent device-rupture rates of 8%–15% at the 10-year-mark since implantation (15%–30% of patients). In 2009, a branch study of the U.S. FDA’s core clinical trials for primary breast-augmentation surgery patients, reported device-rupture rates of 11% at the 6-year-mark. The first series of MRI evaluations of the silicone breast implants with thick filler gel had a device-rupture rate of 1%, or less, at the median 6-year device-age.
Moreover, clinical examination, alone, is statistically inadequate for accurately evaluating the suspected rupture of a breast implant device. The Diagnosis of Silicone Breast-implant Rupture: Clinical Findings Compared with Findings at Magnetic Resonance Imaging (2005) study reported that only 30h% of device ruptures — in asymptomatic patients — is accurately detected by experienced plastic surgeons, whereas MRI examinations accurately detected 86 per cent of breast-implant device ruptures. The FDA thus recommended MRI examinations, as silent-rupture screenings, beginning at the 3-year-mark after device implantation, and then every two years, thereafter. Nonetheless, beyond the U.S., the medical establishments of other nations have not endorsed routine magnetic resonance image (MRI) screening, proposing that such a radiologic screening should be reserved only for cases of the suspected clinical rupture of a breast implant, and for confirming mammographic and ultrasonic studies suggesting a ruptured breast implant device.
Capsular Contracture
The human body’s immune response to surgically installed foreign objects — breast implants, cardiac pacemakers, orthopedic prostheses — is to cover them with scar tissue capsules of tightly woven collagen fibers; bodily integrity by isolation and toleration. Capsular contracture — which should be distinguished from normal capsular tissue — occurs when the collagen-fiber capsule thickens and compresses the breast implant; it is a painful complication that might distort the implant device or the breast, or both. The cause of capsular contracture is unknown, but the common incidence factors include bacterial contamination, device-shell rupture, filler leakage, and hematoma.
Revision mammoplasty: Breast implant complication, the Baker scale Grade IV capsular contracture of a subglandular silicone implant in the right breast.
The device-implantation surgical procedures that have reduced the incidence of capsular contracture include submuscular implant placement, using textured-surface implant devices (polyurethane-coated) limited handling of the implants, limited contact with the recipient-site skin before emplacement, and irrigation with triple-antibiotic solutions.
The correction of capsular contracture might require an open capsulotomy (surgical release) of the collagen-fiber capsule, or the removal, and possible replacement, of the breast implant. Furthermore, in treating capsular contracture, the closed capsulotomy (disrupting via external manipulation) once was a common maneuver for treating hard capsules, but now is a discouraged technique, because it can rupture the breast implant. Non-surgical treatments for collagen-fiber capsules include massage, external ultrasonic therapy, leukotriene pathway inhibitors (e.g. Accolate, Singulair), and pulsed electromagnetic field therapy.
Systemic Disease and Sickness
Since the 1990s, independent, systemic, and comprehensive reviews of the studies for causal links between silicone-gel breast implants and systemic disease reported no device–disease causal link between the silicone breast implants and subsequent systemic and auto-immune diseases. Nonetheless, during the 1990s thousands of women claimed sickness from their breast implants; the medical complaints included neurological and rheumatological health problems. In the Journal of Rheumatology, the article “Where there’s Smoke there’s Fire: the Silicone Breast Implant Controversy Continues to Flicker” (2003) reported that some studies suggested that the psychosomatic (subjective) symptoms and the clinical (objective) symptoms of the women complaining of sickness might improve upon breast implant explantation.
Longer post-operative tracking of augmentation mammoplasty patients yielded much information about the symptomatic incidence of systemic diseases and auto-immune diseases. The Danish national health registry’s breast-implant study reported that women with implants did not risk a greater incidence–diagnosis of auto-immune disease, in comparison to women of the same age group in the general populace, and that the incidence of musculoskeletal disease was lower among women with breast implants than among women who had undergone other types of cosmetic surgery and then among women of the same age group in the general populace. Follow-up longitudinal studies of these breast implant patients confirmed the previously reported findings on the matter.
Furthermore, other studies established that women who underwent augmentation mammoplasty — or any type of plastic surgery — tended to be healthier and wealthier than the general populace, before and after surgery. That plastic surgery patients had a decreased standardized mortality ratio than did breast implant patients and patients for other plastic surgeries, yet had an increased risk of death by lung cancer than other plastic surgery patients. Because only one study controlled the factor of tobacco smoking, the data were insufficient to establish verifiable statistical differences between smoker and non-smoker that might contribute to the greater lung cancer death-rate of women with breast implants. In 2006, a long-term follow-up study of some 25,000 Canadian women with breast implants reported that the “findings suggest that breast implants do not directly increase mortality in women.”
The study, Silicone gel Breast Implant Rupture, Extracapsular Silicone, and Health Status in a Population of Women (2001), reported an increased incidence of fibromyalgia among women who suffered extracapsular silicone-gel leakage than among women whose breast implant devices neither ruptured nor leaked. The study later was criticized as methodologically flawed, and later studies failed to establish such a causal device–disease association. After investigating, the U.S. FDA reported that “the weight of the epidemiological evidence published in the literature does not support an association between fibromyalgia and breast implants.” Nonetheless — excluding the possibility that a small group of breast implant patients might sicken through (as yet) unknown disease mechanisms — the international medical consensus is that silicone-gel breast implant devices neither cause nor aggravate systemic and auto-immune diseases.
Breast Implants and Mammography
The presence of radiologically opaque breast implants might interfere with the radiographic sensitivity of the mammograph. In this case, an Eklund view mammogram is required, wherein the breast implant is manually displaced against the chest wall and the breast is pulled forward, so that the mammograph can visualize the internal tissues; nonetheless, approximately one-third (1/3) of the breast tissue remains inadequately visualized, resulting in an increased incidence of false-negative mammograms. Breast cancer studies of women with implants reported no significant differences in “stage-of-disease” at the time of diagnosis; the prognoses are similar in both groups, with augmented patients at a lower risk for subsequent cancer recurrence or death. Conversely, the use of implants for breast reconstruction after breast cancer mastectomy appears to have no negative effect upon the incidence of cancer-related death. That patients with breast implants are more often diagnosed with palpable – but not larger – tumors indicates that equal-sized tumors might be more readily palpated in augmented patients, which might compensate for the impaired mammogram images. The palpability is consequent to breast tissue thinning by compression, innately smaller breasts a priori, and that the implant serves as a radio-opaque base against which a cancerous tumor can be differentiated. The implant device has no clinical bearing upon lumpectomy breast conservation surgery for patients who developed breast cancer post-implantation, and it does not interfere with external beam radiation treatments (XRT); post-treatment incidence of breast-tissue fibrosis is common, and thus an increased rate of capsular contracture.
Source
“Breast Implant.” Wikipedia.org. Wikipedia, updated 13 June 2011. Web. 16 June 2011. <http://en.wikipedia.org/wiki/Breast_implant>
A significant amount of this information is cited directly from Wikipedia, which is an excellent starting place to learn about breast surgery. We also recommend reading the Strax blog post about maximizing your satisfaction with breast surgery (and minimizing your costs!):
http://www.straxre.com/blog/breast-augmentation-considering-cost-maximizing-your-satisfaction-level/
If you have questions, please call Strax at 954-840-3335 to consult with a Board Certified Plastic Surgeon.
About Strax
Founded in 2004, Strax Rejuvenation & Aesthetics Institute is widely recognized as one of the nation’s leading plastic surgery and wellness centers. Strax has successfully performed over 30,000 surgeries since 2004. To guarantee patient safety and care, all surgeons at Strax must be board certified and credentialed by independent risk managers. All surgeons’ prior medical performance histories are closely scrutinized before they are permitted to perform surgery at Strax’ facility. Supported by a full staff of MD Anesthesiologists registered nurses and physician’s assistants, patients are guaranteed to receive the very best possible experience in a warm, friendly and nurturing environment. Strax Rejuvenation offers Lap Band®® Surgery, Breast Augmentation, Liposuction, Facelifts, Neck Lifts, Hair Grafts, Eyelid Surgery, and Vaginal Rejuvenation. Non-surgical procedures include Fraxel Laser and Lipo X Treatment, Dysport, Restylane, Juvederm, and many more.
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