Breast Anatomy—How It Affects the Breast Augmentation Technique

About 307,000 breast augmentation procedures were conducted in 2011, according to data released by the American Society of PlasticSurgeons.  But despite the growing popularity of this surgery, many patients are still not aware that their breast anatomy and even their overall body frame can affect the final outcome.

Breast Anatomy:

* Areola complex

This is the pigmented part of the skin, and at its center is the nipple which contains tiny ducts responsible for breastfeeding and are very sensitive to manual stimulation.

The edge of the areola can be used as an incision site during breast augmentation, allowing doctors to create a “pocket” and insert the implant.  And while this technique hides the scar, the tradeoff is the higher risk of temporary or permanent loss of sensation which happens if too much nerves are severed.

Fortunately, patients can choose from other breast augmentation incisions including breast crease, underarm, and navel.

* Cooper’s ligament and connective tissue

They support the entire breast and define its shape.  But after several pregnancies and weight loss, they start to become slack, leading to sagging appearance.

Breast implant alone cannot correct sagging, although this can further improve the appearance of the bust after a breast lift surgery.  Combining these two procedures are particularly ideal for women who have drooping breasts and want to add more volume in their chest.

* Inframammary fold

Also called breast crease, it separates the breast mound from the lower chest wall.  Meanwhile, this area is a great incision site because it allows plastic surgeons to work close to the chest, making it easier for them to position the implants; for this reason, the technique is ideal for patients with existing breast deformity.

However, the inframammary fold incision is more ideal for women with a defined breast crease as it can prevent them from having a high- or low-riding scar.

Most board-certified plastic surgeons are very familiar with inframammary incision technique that unsightly scars rarely happen.

* Chest width

This breast anatomy dictates the right implant profile which is the projection off the chest wall.  In general, petite women should use high-profile implant that has small base but offers more protuberance.

By contrast, patients with a wider chest width should use low-profile implants which have a broader base but offer less protrusion.

Meanwhile, patients can choose moderate-profile implants that provide projection according to their amount of filling (which is measured by cubic centimeter or cc).

Saline Breast Implants—Pros and Cons

Saline breast implants are filled with a sterile saltwater, for this reason, a leak will not result to serious health problems although patients will need revision breast augmentation to correct the deflated-looking bust.

Saline implants are not superior to silicone version, and vice versa.  Patients should realize that the most ideal option largely depends on their anatomical features (e.g., amount of breast tissue) and goals and expectations.

Meanwhile, these are the advantages of saline breast implants:

*  Shorter scar.  In the US, only saline implants filled at the time of surgery are available (currently there is no pre-filled saline implant).  Once the shell is inside the breast pocket, plastic surgeons inject this with a sterile saltwater before closing the incisions.

Because an empty shell can fit in a small incision, patients who will use saline implants should not be concerned with visible scars.

* Lower cost.  Saline implants cost less than the silicone version (around $900 to $1300 cheaper).  The difference in price is due to the reason that the cost of production for these implants is lower.

* No risk of silent leak.  In case of rupture, patients will immediately know it right away.  By contrast, women with silicone implants have to undergo regular MRI screening to detect silent leak.

* Slightly lower risk of capsular contracture.  This complication happens when the scar tissue surrounding the breast implants becomes too thick that it squeezes the devices.  Some studies suggest that women with saline implants are at lower risk of having this problem than patients with silicone version.  While the difference is just 1 percent per year, it can be as high as 10 percent after a decade of having the silicone implants.

On the other hand, saline implants have their own disadvantages such as:

* Less favorable cosmetic result.  Because saline implants are filled with only saltwater, women with little amount of breast tissue cannot achieve a natural result.  However, this is usually not a concern of patients with a moderate to significant amount of tissue and fat.

For patients with little breast tissue, silicone implants are the best option.

* Prone to sloshing

Unlike the silicone implants which are notable for simulating the natural “feel” of tissue, the saline version is prone to sloshing because it is only filled with water.  For this reason, some plastic surgeons intentionally overfill the shell to make the implants firmer.

* Natural deflation

One study has suggested that saline implants have a natural deflation rate of 1 percent per year due to evaporation and other factors.  By contrast, silicone implants maintain their for volume for years except in the event of rupture

Breast Surgery—Combining Fat Grafting and Breast Implants

Breast reconstruction via implants for cancer patients who had undergone radiation therapy is often not an ideal procedure due to the high risk of complications for the reason that radiation has toxic effects on tissues, which can impede natural healing for many women.

Because breast implants are not ideal for cancer patients who had radiation therapy, tissue-based reconstruction is the only viable treatment in which their own tissue from buttocks, abdomen, or back is used to create a new breast mound.  However, the tradeoff is longer recovery and muscle weakness and scarring in the donor site.

Fortunately, doctors have found ways minimize the radiation-induced complications, making it possible to use breast implants for post-cancer patients who received radiation therapy.  The staged procedure involves injecting a person’s own fats to her breast so the area will receive a “bed of healthy tissue” in the chest wall.

A recent study published in the February issue of Plastic and Reconstructive Surgery medical journal has proven the promising advantage of combining fat grafting and implants for breast reconstruction.

The three-year study involved 16 patients who underwent the new breast reconstruction technique after receiving radiation therapy to fight off cancer cells.  Eleven respondents had mastectomy (partial or complete removal of breasts) while five had lumpectomy and other types of breast-conserving surgery.

Breast reconstruction began three to six months after the respondents received radiation therapy.

All patients have received two to three fat grafts to place healthy tissue in the chest wall, allowing it to accommodate the breast implants and to lower the risk of radiation-induced complications.

The collected fats from the donor site must be subjected to a purification method to separate biomaterials such as blood and connective tissue; in this way, the survival rate of the grafted fats will be high.

After the staged breast reconstruction, the results were highly encouraging in terms of aesthetic improvements, the researchers concluded.  Also, patient satisfaction was rated high to very high.

Meanwhile, an average follow-up of 15 months did not show any complications as all patients have experienced good healing in their tissue surrounding the breast implants.

Performing radiation therapy after breast cancer surgery significantly reduces the risk of recurrence, although the downside is that the treatment can affect the body’s healing because of its toxic effects.

While the new study revealed the promising benefits of fat grafting with breast implant for reconstruction surgery, the researchers said more comprehensive surveys and trials with longer follow-up are still needed to confirm their findings.

Traditional Breast Lift Surgery Vs Surgical Mesh

Traditional breastlift surgery is conducted by making incisions around the areola, across the breast crease, and vertically down from the nipple to the fold, thus allowing plastic surgeons to excise some of the loose skin and tighten the tissue.  However, one tradeoff a patient should remember is that while it can raise and reshape the bust for a period of time, it cannot stop the effects of gravity and skin laxity.

But recently, plastic surgeons from South Africa have developed a new technique called Internal Bra System which uses a “support” to prevent future sagging.  This method is now also used in Europe.

The new breast lift technique uses a mesh-like device called Breform which is similar to the one used in hernia repairs.  Meanwhile, plastic surgeons who developed the method said the material can take the strain off the scars and skin, preventing the breasts from sagging.

While Breform has not yet been approved in the US, experts believe that it will be introduced to the market within the next coming years.

Breform is a cone-shaped polyester mesh that is placed underneath the breast skin and is attached to the fascia using internal sutures.  The procedure is conducted under general anesthesia that puts a patient to sleep.

Plastic surgeons in Europe who are using Breform said the device is incorporated into the breasts over time, with the body naturally producing fibrous tissue holding the new structure in place.  With this technique, they believe the result is like a permanent support bra under the skin.

However, patients should remember that the new technique also involves the same incision sites used by the traditional breast lift surgery.  This means that the risk of scar and the length of recovery of these two methods are almost the same.

While Breform is approved in Europe, it has not been permitted by the US Food and Drug Administration, which is noted for its strict regulations on medical instruments.  And because the breast surgical mesh is quite new, there is no long-term study proving its effectiveness and safety.

Some US plastic surgeons are also concerned if the mesh-like device may affect the accuracy of screening tests for breast cancer or if it may lead to serious complications.

However, a four-year study involving 170 patients in Holland found no serious complications following the procedure.  The trial also revealed that breast X-ray examinations were still possible after the internal bra surgery.

Breast Implant Size and Things to Consider Before hand

The size of breast implants is measured via cubic centimeter or cc instead of “cup” since every bra manufacturer follows its own standard.  Meanwhile, it is important to note that the volume is not the only thing that affects the final results as there are other contributing factors such as implant profile, shape, and placement.

During the previous years, a significant number of women who asked for breast augmentation wanted larger implants even if it meant having a “heavy” top look.  However, plastic surgeons today see a shifting trend toward smaller sizes to achieve the natural look.

The growing trend can be seen on some Hollywood celebrities who replaced their breast implants with smaller ones.  For instance, Denise Richards and Pamela Anderson have been reported to have undergone revision plastic surgery to downsize their implants.

Another good example is Kate Hudson who has been reported to receive small breast implants in 2010.  And because of the subtle changes in her bust size, no one would even know that she had the procedure if not only for her previous photos and videos showing how flat-chested she was back then.

As a general rule, very large implants will obviously look “fake” in addition to higher risk of complications as the body, especially the back and upper torso, has to carry more extra weight.  For this reason, a good plastic surgeon will make every effort to convince his patient that inappropriate implant sizes can lead to many problems.

The problem with inordinately large implants is that they may lead to premature sagging and tissue thinning as the breasts are forced to carry more weight.  To correct such complications, a revision plastic surgery—which may involve implant replacement or permanent removal of the device—is the only effective solution.

For thin patients, particularly those with limited amounts of glandular fats and tissue, very large implants can significantly predispose them to visible and palpable rippling, or sometimes even traction wrinkling especially if they will receive the textured implants with large size “graininess.”

Another consideration to make is that large breast implants can upset the center of gravity of women, which can affect the way they move.  With this consideration, athletes and patients who live an active lifestyle are generally advised to choose smaller implants to maintain their performance and good posture.

Because of the risk of excessively large bust size, implant manufacturers in the US do not sell silicone breast implants that are over 800cc.

Breast Implants with Lift for saggy boobs

Even small breasts can sag due to the natural effects of aging, weight fluctuations, and previous pregnancies.  Fortunately, plastic surgeons have come up with a new technique which combines the benefits of mastopexy (or breast lift) and breast augmentation in one operation.

The sagging of the breasts primarily happens when the amount of tissue decreases and the skin becomes lax.  Contrary to popular belief, breast augmentation surgery alone is less likely to provide a lifting effect especially if there is a severe case of ptosis (drooping).

Mastopexy with breasti mplants starts by making incisions to remove a small amount of skin, which in turn corrects the sagging appearance.  With this technique, less tissue is excised than if breast lift is performed alone; for this reason, patients will enjoy less scarring on their chest.

Because less skin is removed, plastic surgeons need shorter incisions to perform mastopexy-augmentation surgery.  In most cases, they use the crescent-shaped incision around the areola complex, although patients with severe breast ptosis may need the lollipop incision in which the surgical cut is made around the areola and vertically down the breast crease.

The good thing with mastopexy-augmentation is that most patients can get more cleavage, although they should bear in mind that the final result also depends on their chest width and rib cage.  For example, women with a concave chest are likely to enjoy more medial cleavage and upper pole fullness as the implants tend to settle toward the center.

On the other hand, patients with convex chest will achieve less cleavage because their implants will likely settle opposite with each other.  However, there is a solution to the problem: use breast implants that offer more projection off the chest wall.

While some surgeons prefer simultaneously performing breast augmentation and mastopexy, others would rather wait for three months before another surgery (augmentation) is conducted.

Some doctors argue that breast augmentation with mastopexy—if performed on the same day—can lead to higher risk of asymmetrical breasts and complications since the skin is being removed and tightened while at the same time the implants stretch it even further.  Another concern is the tension on the incision site can adversely affect the blood supply.

They also argue that it is challenging to position the nipple and breast crease if mastopexy and breast augmentation are performed simultaneously.

Regardless if breast augmentation is performed on the same day of mastopexy or at a later date, most plastic surgeons recommend placing the implants totally under the pec muscle which can provide good coverage and strong “support.”

Patient Options in Breast Augmentation Surgery

The primary goal of breastaugmentation is not just about increasing the bust size but also making the result as natural as possible.  Fortunately, this is easier nowadays as breast implants come in different sizes, shapes, shell, filling, and projection, in addition to a wide range of surgical techniques used by plasticsurgeons.

Nowadays, three options in breast implant placement are available for patients: complete submuscular (under the muscle), partial submuscular (partially under the muscle), and subglandular (behind the tissue).  These surgical techniques have their own pros and cons which are carefully explained to women so they can decide for themselves.

The complete submuscular implant placement results to longer recovery and more pain during healing period because the pec muscles are stretched and pushed.  However, the technique provides countless of benefits such as more coverage to reduce the risk of implant wrinkling; more lifting effect; better mammogram reading; and lower risk of capsular contracture, which is a condition resulting to hardening of the scar tissue around the implants.

On the other hand, the subglandular implant placement results to shorter recovery because the pec muscle remains intact.  But since no muscle covers the implant shell, the technique is only ideal for patients with enough glandular tissue, fats, and skin.  Another consideration to make is that an ongoing ptosis (drooping) may be further aggravated because of the lack of strong “support.”

Meanwhile, the partial submuscular combines the benefits of subglandular and complete submuscular implant placements.

Aside from the implant placement, the type of implants can also have a significant impact on the final result.  For instance, women who want to achieve more cleavage are advised to choose round implant rather than the teardrop-shaped version, although the latter is more notable for simulating the natural contour of the breast.

Breast implants are either filled with saline or silicone gel.  For those who want to achieve a more natural “feel” and “look,” and women with a limited glandular tissue, the silicone implant is a better option; however, one downside is that the patients are required to undergo MRI screening every two years to detect any asymptomatic or “silent” leak.

On the other hand, women with saline implants are not required to have a regular MRI screening because a leak is easily manifested by deflated-looking breasts, making it possible to immediately seek revision breast augmentation.

Regardless if saline or siliconeimplants are used, their size should not only be based on one’s goal but also on her body-frame, amount of tissue and skin, and chest width.  It is important to note that a good plastic surgeon will not push the body’s limit by introducing implants that are too large for it.

Breast implants can be inserted via four incision sites: axillary (armpit), TUBA (navel), breast crease, and areola complex.  Patients should remember that the best surgical technique largely depends on their goals, acceptable risk level, and type and size of implants.

The axillary and TUBA incision sites require the use of an endoscope, which is a fiber optic camera attached to a large monitor.  Through this instrument, plastic surgeons can insert an empty saline shell inside the breast pocket and then fill this with a sterile saltwater solution.

But because the axillary and TUBA incisions work farther away from the bust area, there is a greater margin of error.  By contrast, the breast crease and areola incision sites provide surgeons with greater control over the final result of the surgery, making them a more popular choice.

Since there are many surgical options and type of implants available for women, breast augmentation typically involves lengthy consultation between patients and plastic surgeons.  In this way, doctors can also determine if the goals and expectations of a person with the surgery are plausible and achievable.