Preoperative assessment and planning of the aesthetic breast patient

Introduction

Breast augmentation continues to be one of the most frequently performed aesthetic operations performed around the world with over 300,000 cases per year performed in US alone and is the most common indication for the use of breast implants. With time, heightened patient and surgeon expectations have evolved along with improvements in implant technology and surgical technique. These trends have equated to a rise in the number of revisionary procedures performed, which can be as high as 30% to 40%. The most common reasons for revision surgery include capsular contracture, implant malposition, asymmetry, implant rupture, desire for size change, ptosis, wrinkling/rippling, or hematoma/seroma. In order for a breast augmentation practice to advance and improve, surgeons must constantly strive toward fewer complications and reoperations, achieving more predictable long-term results and provide for an enhanced patient experience. The surgeon must be attentive to patient communication to ensure that expectations are realistic as well as adhere to certain principles, both during implant selection and surgery. As with any craft, the improved outcome can only be achieved by adhering to the fundamentals, which will be the focus of this chapter. There are three determinants of a successful implant-based breast surgery: patient factors, implant factors and surgical factors.

Patient factors

Like all surgical procedures, the process starts with the initial consultation. During the consultation, it is imperative to evaluate several factors that are related to both the patient’s state of mind and body characteristics. Central to the process of selecting patients for any type of aesthetic surgical procedure is the well-being and safety of the patient. The surgeon and staff must be able to differentiate between patients who are stable and informed in contrast to those that are impulsive and emotionally unstable. Furthermore, patients under age 18 cannot consult without an accompanying parent. When considering saline- and silicone gel–filled implants, it is important to recall that silicone gel devices are permitted by the Food and Drug Administration (FDA) in patients 22 years and older. Saline-filled devices can be used in patients aged 18 and older.

Correctly selecting patients is difficult and requires a combination of factors. It requires verbal communication skills, genuine interest in the patients, and the ability to listen. While some of these capabilities can be learned through academic studies, optimal patient selection is facilitated with experience. For the novice plastic surgeon, it is important to have had proper mentorship. Wrongly scheduling a patient for surgery can be detrimental to the patient, the surgeon and the surgical practice. At times, the best surgery is the one never performed.