What you need to know about Breast Augmentation

The following is generic advice for those of you who are contemplating having breast augmentation. There have been complete textbooks written on each of these topics but it is meant to be an overview and therefore has been kept very brief. There is no universal approach that will suit everyone. You should consult your surgeon and make a decision based on professional advice.

Incision

IMF (Inframammary fold)

This incision is placed in the fold under the breast. It allows for large implants to be put in through a small hole and all the dissection is done under direct vision. Typically the scar will be 4-5 cm in length. This is the most common approach used by plastic surgeons.

Periareolar

• • A semicircle incision usually done at the lower border of the areola. This is incision has gone out of favour for a few reasons:
    • There is a slightly higher risk of nipple sensory loss.
    • The dissection proceeds through breast tissue and therefore the risk of capsular contracture is slightly higher.
    • The incision is visible on the front of the breast.

The major advantage to this approach is if you need a small lift or your areola is larger then this can be done through a periareolar approach.

Axillary

Placed in the armpit this scar is the least visible of the commonly used scars. Once again it has gone out of favour.
The reasons are:

• The dissection must be done in a blunt fashion and not under direct vision
• It is more difficult to get the pocket accurate for the implant to sit in
• If there is bleeding it is difficult to control
• It is best used with saline implants (which are rarely used)

Umbilicus

Only to be mentioned here for completeness, it is very rarely used and can only be used with saline implants.

Anatomical plane

Subglandular – the implant is placed behind the breast tissue but in front of the pectoralis major muscle. Anatomically this is where breast tissue is supposed to reside so it makes a lot of sense to place an implant here.
Subpectoral – This plane is deep to the pectoralis major muscle which sits behind the breast. Also referred to as submuscular, the major advantage of this plane is in patients who may need more soft tissue coverage over the implant.  A major disadvantage of this approach is that the muscle over time can cause the implant to descend – this is referred to as bottoming out. You will also notice a term called animation which is where the implant is pushed down and out when the pectoral muscles are used. Please note that if an implant is put in the subpectoral plane, the muscle only covers the upper 60 – 70% of the implant, therefore it should be considered as best used to disguise the upper pole.
Subfascial – There is a very thin layer of fascia or tissue which lies on top of the pectoralis major muscle. Some surgeons believe that placing the implant in a subfascial plane confers added benefits however is most cases it is the same as a subglandular plane.
Dual Plane – This is a fancy term for subpectoral but it is subtly different. I won’t get too technical but there are 3 types of dual plane of which one is the standard Subpectoral approach. The other 2 involve varying dissection of the breast gland off the muscle in order to create 2 planes – ie dual plane. In a nutshell it involves a full subpectoral dissection and a partial subglandular dissection. It is most commonly used in patients with excess skin in their lower poles who need to create more expansion of the lower pole than a traditional subpectoral approach can give.

There is no universal approach that will be suitable for everyone. Each patient at Horizon Plastic Surgery will have their operation customised to suit their needs.

Saline or Silicone

It is important to note that both saline and silicone implants are covered by a silicone shell.
In Australia silicone implants are the most commonly used by far.

The reasons for this are numerous but include:

• Patients prefer the aesthetic results
• Patients prefer the feel
• They have less wrinkling
• If they have a leak the implant doesn’t deflate and cause you to be lopsided.

Basically there are only 2 advantages to saline implants – they have a proven lower capsular contracture rate and if they deflate then the saline will be resorbed by your body. The disadvantages are numerous as listed above. In addition the leak rate is higher because it has a weakness in the shell where the valve is placed for filling it with saline.

Types of Implant shell

Smooth – As its name suggests the outer silicone coating is smooth. (This is the case for all saline implants.) They are only available in round implants.

The main issues are –

• Can be put in through a shorter incision
• Offers a more mobile result
• Higher incidence of wrinkling
• Best used in the subpectoral plane

Textured – The outer shell has a rough coating which is supposed to stick to the tissues better. The initial reason for textured implants was to try and minimise capsular contracture although there is scant evidence that this is actually true.
There are different methods of creating the textured silicone coatings but they are all relatively similar. They tend to not move as much as a round and are safer to use in the subglandular plane. The implants tend to feel firmer than smooth implants.
NB All anatomical or tear drop shaped implants are textured.
Polyurethane (PURE) – These are silicone implants which have polyurethane embedded in the outer shell. This gets metabolized by the body over time and has been proven to have a lower rate of capsular contracture. It feels like velcro and in general is a more difficult implant for the surgeon to use because it is harder to insert and remove.

Shape of implant

Round – These implants are shaped similar to half a sphere and are flat on the back to sit on the chest wall and rounded on the front. They have differing degrees of projection depending on which implant is chosen. In general terms they give more projection in the upper pole.
Anatomical (teardrop) – These implants more accurately reflect the shape of the breast. They are used much more commonly in breast reconstruction but also have indications for use in breast augmentation. Generally speaking they have a less prominent upper pole. They are most commonly used in patients with minimal tissue coverage.

Summary

Confused?? Don’t sweat it too much. That’s why we recommend you consult with qualified practitioners who have had surgical training and are registered with the Australian Society of Plastic Surgeons. So whilst we encourage you to make your own decisions please try and keep an open mind when you see your surgeon as this is generic advice only.

Also please remember that for a lot of women having breast augmentation the subtle changes that I have discussed above can sometimes be very minimal.

This opinion piece was brought to you by Dr Damien Grinsell.