What to consider before breast augmentation

Breat-augmentation_WB

From the shape and type of the breast implant through to the incision site and placement, there are many variables to consider before undergoing breast augmentation.

For many women, breast implant surgery brings great rewards, both physically and emotionally. However, before making a decision to undergo breast augmentation surgery, it is important to consider all the options available.

Making a choice may seem overwhelming when you first investigate all the factors involved. There is no one breast implant type, size, shape, texture, location placement and incision site for everyone. A thorough consultation with your surgeon – taking into account your body shape, existing breasts and individual circumstances – is essential to best achieve your goals, desires and expectations.

Types of implant

There is an extensive range of breast implants available in Australia and there is a type to suit just about everyone. Implants are either saline or silicone-gel filled and are produced in round and teardrop (anatomical) shapes, with a smooth, textured or polyurethane foam-covered surface. Saline-filled implants

Saline implants have a silicone outer shell that is filled with a medical-grade saltwater solution which is biocompatible. The implant can be filled through a valve during the procedure to a fixed or non-fixed volume, or it can be prefilled to a determined volume during manufacture. Saline implants generally feel firmer than silicone gel implants and due to their thinner consistency they tend to wrinkle more readily. Deflation is also a potential problem and requires replacement if this occurs. Saline implants can also be relatively under-filled in the upper part and be subject to rippling in their upper aspect.

Silicone gel-filled implants

Most implants used in Australia are silicone gel filled. Silicone is regarded as one of the most compatible materials for implanting into the body and is commonly used in medical devices and medicines.

Modern silicone gel implants are vastly superior to the silicone implants of 10 to 15 years ago. The silicone gel is cohesive, meaning it is pre-shaped with a viscous, Turkish Delight-type consistency. Because the gel is not runny or liquid in property, its use in breast implants minimises the risk of leakage problems.

Many surgeons and patients also find silicone implants generally feel softer and more like natural breasts than saline implants.

Size

Your body shape and individual preferences are the main determinants of implant size. Breast implants do not come in cup sizes but instead come in cubic centimetres (cc). Discussing your desired breast size with your doctor, trying on different implant sizes and shapes in your bra and looking at before and after photographs from breast augmentation procedures can all help you to choose the most appropriate size for your body.

Shapes and forms

There are generally two different forms of breast implants: round or teardrop (anatomical) shaped.

Round implants, depending on their fill, can give a defined round shape or assume more of a teardrop form when the patient is upright. They tend to provide more upper pole fullness than anatomical implants, which are fuller in the lower pole.

Anatomical implants demand a greater degree of accuracy in positioning, and if they shift after surgery the shape of the breast may be distorted. They normally have a textured surface to avoid rotation.

Anatomical implants can also provide greater projection in proportion to the size of the base, making them particularly suitable for women with little natural breast tissue. While the size of the base of the implant is limited by your chest wall, the choice of projection is to a large extent a personal one. If you have adequate breast tissue and a shape you are happy with, you may opt for a low-profile implant that will simply increase the size of your breasts. If you wish to create cleavage or if your breasts have some degree of sag, a high-profile implant might be a more suitable option. Your surgeon can help you with this important aspect of implant selection.

Smooth vs textured

The shell of a breast implant can be either smooth or textured. Smooth implants may achieve a smoother look and feel in some patients, but generally have a greater risk of capsular contracture.

Capsular hardening is the most common complication in breast augmentation surgery. It occurs when the body forms a capsule of fibrous tissue around the implant, which can make the implant feel hard and often distort its shape. Secondary surgery is required to correct this problem. Textured implants tend to minimise the incidence of capsular contracture and promote tissue adherence, which may help maintain proper implant positioning.

New Brazilian breast implants, recently approved for use in Australia by the Therapeutic Goods Administration, have a polyurethane foam coating that grips the tissue, meaning there is less likelihood of rotation. Its unique surface significantly decreases the risk of capsular contracture – the foam covering becomes part of the capsule and makes it less prone to contracting.

Incision sites

There are generally four choices for the incision site and the decision is mostly up to you. They each have their advantages and disadvantages.

1. Inframammary

The inframammary incision is made in the crease under the breast close to the inframammary fold. The surgeon creates a pocket for the breast implant, which is slid up through the incision, then positioned behind the nipple.

The scar is hidden in the crease under the breast and is not normally visible when wearing a bikini top.

This incision offers the best exposure for visualisation and allows the implant to be placed in a precise pocket formation. There is some uncertainty involved in placing the incision with regard to its position on the augmented breast. While this is not a problem for an experienced surgeon, it can present difficulties when there is little breast tissue or natural crease.

2. Periareolar

The periareolar incision is made around the nipple near the area between the dark areola and surrounding breast skin. It is made at the outer limit of the areola so that there is areola skin on both sides of the incision where scarring is least visible.

The breast implant is inserted through the incision into a prepared pocket, then positioned behind the nipple. One advantage is that there may be no visible scar because of the colour and texture of the areola. This incision allows the implant to be placed precisely in the pocket formation. The disadvantage is that it involves cutting through breast tissue and ducts and sensitivity in the nipple may be reduced. Any complication in healing is highly visible in the scar.

3. Transaxillary

The transaxillary incision is made in the natural crease of the armpit and a channel is created down to the breast. This may be performed with an endoscope (a small tube with a surgical light and camera in the end) to provide visibility. The implant is inserted and moved through the channel into a prepared pocket, then positioned behind the nipple.

The scar is virtually invisible in the armpit fold and lack of tension generally allows for straightforward healing. There is no scar on the breasts.

Disadvantages include the fact that the transaxillary site is relatively far from the breast, where the surgeon needs to create a pocket to house the implant, so visibility is limited. There is also a higher incidence of the implant being placed too high. If the scar heals poorly it is noticeable in bikinis and sleeveless tops. If capsular contracture develops another incision will be necessary for treatment.

4. Transumbilical or navel (TUBA)

The TUBA incision is made on the rim of the navel. A tunnel is made under the skin through the subcutaneous fat layer on the torso into the layer of loose tissue between the breast and pectoral muscles.

An endoscope can be used to create the tunnel and to provide visibility to the surgeon. After a pocket is created in the breast, the implant is inserted through the incision and moved into the breast area, then positioned behind the nipple.

There are no incisions or scars in the breast area, however this site can only be used for saline implants. The distance of the incision from the breast can reduce the surgeon’s ability to control bleeding and to position the implant correctly. If capsular contracture develops, another incision will be necessary for treatment.

Implant placements

Factors such as the quantity of breast tissue, natural breast size and symmetry, the dimension and shape of the chest wall, the amount of subcutaneous fat and the quality of breast skin will influence your doctor’s decision as to the placement of the implant.

Placement of the implant can help determine the result of breast augmentation. It is important you are well-informed about the options available as well as the suitability of each option for your individual body type.

Generally, there are three placement options: subglandular (in front of the muscle), submuscular (behind the muscle), and dual plane (partially under the muscle).

Subglandular

The subglandular pocket is created between the breast tissue and the pectoral muscle. This position resembles the plane of normal breast tissue and the implant is positioned in front of the muscle. Sometimes the implant is covered by a thin membrane, the fascia, which lies on top of the muscle. This is called subfascial placement. This position is suitable if you who have sufficient breast tissue to cover the top of the implant. This procedure is faster and may be more comfortable for the patient than submuscular placement. The implant moves more naturally in this position.

One disadvantage is that there may be more bleeding. If you are thin and do not have sufficient breast tissue, the edge of the implant may be visible. Any rippling of the implant will be more noticeable in this position. With smooth implants, some studies have reported an increase in capsular contracture with this position.

Submuscular

The implant is placed under the pectoralis major muscle after some release of the inferior muscular attachments. Most of the implant is positioned under the muscle.
This position creates the most natural-looking contour at the top of the breast in thin patients and those with very little breast tissue. There is a decreased chance of visible and palpable implant edges or rippling.

There may be more postoperative discomfort and a longer recovery period. The implants may appear high at first and take longer to drop. The ‘Snoopy’ deformity where breast tissue falls downwards and forwards away from the implant is more common with this placement.

Dual plane

The implant is placed partially beneath the pectoral muscle in the upper pole, where the implant edges tend to be most visible, while the lower half of the implant is in the subglandular plane.

This placement is best suited if you have insufficient tissue to cover the implant at the top of the breast but need the bottom of the implant to fully expand the lower half of the breast due to sag or a tight crease under the breast. This position helps to minimise the rippling and edge effect in thin patients while avoiding abnormal contours in the lower half of the breast. It does, however, involve more complex surgery, which if not performed correctly may result in visible deformities when the pectoral muscles are contracted.