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 our professional advice.
Incision
IMF (Inframammary fold)
This incision is placed in the fold under the breast and virtually not noticeable in most patients. 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 most 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 too large 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 thin patients who need more soft tissue coverage over the implant. It gives a slightly more natural looking result. 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 customized 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 they can be summarized by stating that overall the cosmetic result is better.
- They look better
- They feel better
- 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 natural 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 smaller incision
- Gives a more mobile and natural 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 prevent capsular contracture although there is scant evidence that this is actually true. See LINK to capsular contracture.
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. The look and feel of the implant is less natural.
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 and therefore more wow factor.
Anatomical (teardrop) – These implants more accurately reflect the normal 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 and a more natural shape. They are most commonly used in thin patients with minimal tissue coverage and in those patients who want a more natural look.
Summary
Confused?? Don’t sweat it too much. That’s why you see professionals like us at Horizon Plastic Surgery who have had many years of surgical training and are registered with the Australian Society of Plastic Surgeons. Whilst the information above can be confronting and confusing it is usually quite clear to your surgeon what will give you the best result. 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. Your surgeon will usually be able to point you down the correct path with minimal concern on your part.
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. For more information or an appointment please call 03 85602999 or email enquiries@horizonplasticsurgery.com
