Primary breast augmentation with implants

Medical history

In the author’s practice the patient’s physical health is carefully evaluated by the surgeon in charge and the anesthesiologists. Surgery can be scheduled if the medical risk of the procedure, including anesthesia, is expected to be negligible. Furthermore, if the patient has an ongoing psychiatric condition she should have documentation from her treating doctor, stating that she is suitable for surgery and that the procedure will not worsen her condition. We also screen if patients might have Ehlers-Danlos syndrome, since our experience is that regardless of what type of implant, these patients have a higher incidence of complications, most likely due to the syndromes underlying condition of general tissue laxity.

Patient motivation

During the consultation, the patient should seem comfortable with her decision and not be hesitant. It is imperative to ascertain that it is the firm will of the patient herself to follow through with a breast augmentation. Ideally, the patient should have thought through the consequences of the procedure and it should not be a spur of the moment decision.

It is important to ensure that the patient is in a stable, well-balanced social situation and that she has not recently experienced an emotional trauma, such as a divorce. Even though many patients state that they have been considering the procedure for as long as they can remember, the standard questions should always be “… why have you decided on having this procedure right now?”.

As when dealing with any cosmetic surgical procedure, it is important to exclude patients suffering from body dysmorphic disorder, as surgery might reinforce the condition. During the consultation it often becomes evident if a patient is suffering from body dysmorphic disorder or not, due to lack of a balanced proportional emotional correlation to the patient status. At times a few screening questions are required. If the patient has a history of bulimia or anorexia, she should have been declared healthy at least 6 months prior to the consultation.

Patient information and education

Each patient should be made as knowledgeable as possible of the procedure that is facilitated by providing preoperative information that is comprehensive and easy to understand. The information may be delivered through an informative continuously updated website and by oral and written information. If the patient is well informed prior to the consultation, the discussion between the surgeon and the patient becomes more meaningful and the patient can participate more actively in the choice of implants. To understand what the patient is looking for; the surgeon must be attentive and may pose standard questions such as, “Would you be satisfied if you were given the same breasts that you have today but a bit larger?” and “Please explain to me what it is you think your breasts are lacking?” If the patient has had previous pregnancies a question like,” Did you like the shape and size during pregnancy,” might assist in understanding patient expectations.

Although the combination of cohesive gels and certain texturing might allow more predictability of shape and stability of the breast over time, the possible long-term consequences with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a disease more associated with textured or polyurethane (PU) implants, must be taken into consideration when guiding the patient. The SCHEER (Scientific Committee on Health, Environmental and Emerging Risks) provides an excellent update on the safety of breast implants in relation to anaplastic large cell lymphoma. The alternative to textured devices might be a smooth surface device that over time could exert pressure on the skin and parenchyma with changes occurring over time due to gravity. Causing sequelae such as pain, bottoming out and malpositioning of the implants; all of which must be discussed with the patient. It is therefore necessary for the surgeon to have a thorough ongoing discussion with the patient regarding all different aspects associated with breast implant surgery. It is imperative that the patient understands the change that may occur to the augmented breast due to changes in body weight, pregnancy, breastfeeding, aging and time. All of these could affect the shape and size of the natural existing breast and that additional breast surgery might be required at some point in the future due to this or implant failure. The patient should also be aware of the risk of capsular contracture and its consequences.

Patient expectations and requests

It is the surgeon’s responsibility to inform the patient what result regarding shape and size is achievable given her specific body characteristics. Involving a patient in the implant selection process is a must. In this process, patients might present unrealistic expectations that make them unsuitable for surgery. An example is the very thin patient with ptotic breasts in need of a submuscular breast augmentation for sufficient soft tissue coverage, but who refuses a necessary mastopexy and subglandular implant placement.

Whether a patient requests an implant that is too small or too large is often a topic of discussion with a variety of opinions. Although an implant that is too small may result in a less than optimal outcome based on a proportional analysis, an implant that is too large may also result in a less than optimal outcome but for other reasons such as bottoming out, malposition, pain, thinning of tissue, and rippling, to name a few.

The goal of the plastic surgeon should be to strive for maximal patient satisfaction scores while at the same time, minimize complications and reoperation rates. In order to achieve this, plastic surgeons need to explain and express to patients that there are potential and significant risks associated with selecting an implant that is too large and disproportionate. This can be challenging because many patients have a certain volume in mind and are resistant to change. In these circumstances, it may be prudent for plastic surgeons to reject certain patients for surgery. Thus, patients should be denied surgery if they do not comprehend this and / or they request unreasonably large implants as compared to the volume and shape that the surgeon recommends based on dimensional planning and long-term success based on the quality of breast soft tissue. Therefore, in my practice, patients that show a lack of interest or failure to participate in the learning process are not considered as optimal patient for an operation. Patients are also asked to bring photos of desired breast look to guide the surgeon.

Pre- and postoperative planning, implant selection and follow-up protocol ( Fig. 3.1 )

It helps the surgeon and patient to assess and document the examination, and is used in the following order:

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  The patient’s satisfaction self-assessment of her breast, 1–10, prior to surgery.

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  Breast tissue assessment (tight, average, loose, ptotic skin) and characteristics (aplasia, hypoplasia, asymmetry, tuberous) pinch test and skin stretch.

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  Measurements of the breast prior to operation on a drawing of a female torso.

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  Patient preferred shape of breast with drawings of anatomical to more round breasts.

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  Implant choice and selection (brand, model/ size, placement, incision).

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  Type of additional surgery, if required, beside the breast augmentation.

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  Long-term follow-up with drawings of female torso.

Patients’ satisfaction self-assessment of her breast, 1–10, prior to surgery

The author asks, on a scale from 1 to 10, how they rate their satisfaction of shape and size of their breast at the consultation prior to surgery and at their follow-ups 6, 24, and 48 months post-operation. Over the years, the author has asked thousands of patients about their self-assessment and the average score prior to surgery has been 3.15 and average score postoperatively at 6 months’ follow-up has ranged from 8.98 to 9.2, depending on type of implant ( Fig. 3.2 ).

Not only does this scoring system assure a baseline for assessing satisfaction after surgery compared with before, but it also provides easily understandable information about how these patients perceive their breasts before surgery. The author has over the years understood that a patient who scores her breast at 6–7 prior to surgery might be a poor candidate for breast augmentation. A patient scoring 6–7 regardless of whether she has aplasia mammae or the perfect proportionate breast is more likely to be dissatisfied by the fact that she is not able to objectively rate her breast, because the author knows that most patients with aplasia mammae would score 1–3 and those with perfect proportions would score 8–9. This scoring system has nothing to do with self-esteem or quality of life. It is merely a way of rating of how the patient assesses her breast in relation to other breasts. If this assessment is not a balanced one the patient might have a weaker, unhealthier relation to her breast and therefore is at risk for unrealistic expectations following breast augmentation. We have found this system very satisfactory in assisting us with patient selection. It also gives us a true baseline and prospective analysis of satisfaction over time.

Breast tissue assessment and characteristics

The implant selection process involves the surgeon’s understanding of the patient’s expectations and a careful assessment of the patient’s chest wall and breasts. The surgeon together with the patient should choose implants based on the patient’s chest wall and existing breast tissue, altering the distribution of gel volume using different kinds of implants, surfaces to create the desired shape, volume, and stability of the breast.

It is the author’s strong belief that the assessment of the breast and selection of implants should be done preoperatively during the consultation by the surgeon who is going to perform the surgery. The consultation should preferably take place in a peaceful environment, in front of a mirror where the patient is given the opportunity to express her desires, with the surgeon positioned in an inferior, less hostile position ( Fig. 3.3 ).

The characteristics of the patient’s chest wall and natural posture ( Fig. 3.4 ), existing breasts, and breast implants together determine the final result. Understanding the differences in body configuration and choosing the correct implants for optimal result is imperative. A tall chest might benefit from a tall implant, while a short chest might benefit from a short implant however most patients do well with a round footprint. A more projected chest might need less implant projection in order to reach the same ( Fig. 3.5 ). Assessing tissue and skin quality, understanding the difference of a tight, average, loose or ptotic breast envelope and the long-term consequences of the breast shape depending on breast envelope and implant choice is imperative. Understanding that different implant surfaces and sizes affect the breast tissue differently is important and will be discussed further in this chapter. Optimal implant choice and selection might also depend on whether the patient presents with aplasia, hypoplasia, asymmetry, lower constricted pole, or a tuberous breast. Pinch test in the upper medial quadrant and skin stretch are also measured.

Patient measurements

Another important aspect of proper implant selection is the need to obtain measurements of the patient’s chest wall and breasts. The measurements should include the base width (BW), the nipple to IMF distance that should be measured under maximum stretch (N-IMF), the intermammary distance, sternal notch to nipple distance (SN-N), a pinch test of the tissue in the breasts’ upper pole and a skin stretch test. The BW is the most important measurement during implant selection. By choosing an implant that is not too wide, the risk of future problems such as rippling, implant visibility, bottoming out or skin stretch is minimized.

The BW is measured from anterior axillary line to the medial demarcation of the breast that borders on the “no touch zone”. In patients who are having submuscular implant placement, the “no touch zone” marking is an area measured 1.5 cm away from midsternal line on both sides that totals 3 cm in width. In patients who are having subglandular implant placement, the “no touch zone” marking is an area measured 2 cm away from midsternal line on both sides that totals 4 cm in width. The SN-N distance provides a hint on the optimal height of the implant. Another critical assessment is that of the patient’s posture and the projection of her upper chest wall. The pinch test in the upper medial quadrant guides the surgeon regarding the choice of whether to place the implant in the submuscular or the subglandular position. Sufficient tissue coverage is important so that the implants do not become visible in the long run. In the author’s practice, highly cohesive, firm implants are thought to require more tissue coverage than less firm and cohesive viscous smooth nano implants. It is the author’s observation that more firm, cohesive implants will stretch and shape the overlying breast tissue; however, due to its firmness, the implant may also result in a thinning of the breast soft tissue over time. Firm, less viscous, highly cohesive implants should therefore be placed more often in the submuscular plane.

Given the great diversity of implant sizes and shapes, the implant selection process should be made as simple as possible, and the young plastic surgeon should be able to master the process of implant selection after a minimum of practice. It is the author’s’ experience that more than 80 % of the cases can be solved by using a handful of different implants and a standardized surgical technique. However, the full range of matrix with its diverse pallet of implants allows the surgeon striving for perfection to challenge and solve minor to more difficult cases regardless of breast and chest wall asymmetries.

Implant choice

A section of the preoperative planning and implant selection sheet (see Fig 3.1 ) has three different drawings of anatomical to more round breasts shapes, where the patient can choose the preferred shape.

During recent decades, the range of implants on the market has steadily increased. Several implant systems from different manufacturers are now available with anatomical, teardrop-shaped implants varying in height, width, and projection as well as round implants varying in diameter and projection. These implants can be offered with different types of surfaces, ranging from smooth, micro, macro textured to polyurethane. Various types of fillings from saline to silicone gels of different properties are offered to doctors and patients that range from firm light-weight silicone spheres to very soft, highly cohesive gels with low viscosity.

Given the great implant diversity, it is now possible to find and fit an implant for virtually all patient’s feature and desire. This enables fine tuning and correction of even the most severe cases of breast asymmetry and serves as a tool in a surgeon’s constant strive toward perfection. The process of selecting the correct breast implant could be standardized in most cases, but sometimes represent a great challenge when meeting the complete spectrum of patient types seeking breast enhancement.

In the author’s practice, breast implants from different manufacturers are available with anatomical, teardrop-shaped implants varying in height, width, and projection a s well as round implants varying in diameter and projection. These implants can in primary cases be offered with different types of surfaces, ranging from smooth-nano, microtexture to polyurethane. Various types of fillings from very soft, highly cohesive gels with low viscosity to firmer, highly cohesive gels with less viscosity are used. Both anatomic and round textured cohesive gels are incorporated in the author’s matrix concept as well as round nanotextured smooth.

In general, anatomical microtextured implants might have their advantage in primary cases where a certain shape or specific volume distribution is desired and of more importance then just added volume. This is especially true for thin patients and for correction of a lower constricted pole or severe breast asymmetries, especially ex cavatum. It is also favorable when a patient requests for a larger breast implant to ensure stability of implant positioning over time. When using texture, the author prefers a microtextured implants with a firmer cohesive silicone gel and submuscular positioning, as these provide excellent control over the aesthetic result both short- and long-term. The submuscular position offers a lesser risk of rippling and implant visibility due to more tissue coverage, as described previously. Microtextured or polyurethane implants that interact with the surrounding tissue in a tight pocket with true friction or tissue ingrowth, will create what the author describes as” controlled tissue expansion” and implant stability in the pocket.

Friction will cause a more reactive and inflammatory response and therefore development of capsule. Once the implant has regained its predesigned shape, that initially was distorted because of the tight pocket, and original shape of breast, the desired and final breast look based on design, shape, and volume distribution of the implant will become evident after 3 months. Thus, the implant will usually maintain its shape and position over time.

For those patients who present with a well-balanced breast yet still desire a fuller look, a softer feel, with a smaller implant, it is the author’s preference to use a smooth round silicone gel implant that is usually placed in the subglandular location. This also applies to patients who after a thorough information on BIA-ALCL express concerns about having a microtextured implant. The subglandular placement of smooth implants has historically been associated with capsular contracture; however, personal experience with nanotextured smooth implants placed subglandular with aseptic non-traumatic surgical technique, has shown that capsular contraction is a non-issue. Smooth implants do not interact with the surrounding tissue the same way as textured implants that are associated with true friction; thus, smooth implants are less inflammatory to their surroundings. Even though positioned in a tight pocket, respecting coopers ligaments, depending on implant size, tissue, and skin quality, a smooth implant might create what the author describes as “an uncontrolled tissue stretch”. There are multiple factors that play a role in this. As previously mentioned, implant size is important in relation to tissue and skin quality. If these are poor in quality, even a smaller volume implant might result in malpositioning and bottoming out, whereas in a patient with good skin and tissue quality, a larger volume implant may remain stable in position.

With a smooth implant, it is more difficult to predict the long-term result based on the volume of the implant and the effects of gravity on the stability of the surrounding soft tissues and how it will impact implant position This was described earlier such that there is nothing about the implant surface and its lack of interaction with the surrounding tissue that ensures stability except for the development, quality, and thickness of a capsule. Therefore, it is extremely important for all surgeons to gain experience by following their own patients over time, measuring, and assessing skin and tissue stretch of the breast, especially in relationship with implants used with, most importantly, their own surgical technique. By doing this, surgeons can understand the effects of “big” or “small” implants as well as “good” or “poor “skin tissue quality, in their world, since these are variables that are difficult to describe in a numeric, scientific way.

Implant selection

The sheer number of available implants might at first seem daunting, but as the chest wall shape and breast size among females in a uniform population usually does not vary greatly, a relatively small number of implants is required to solve most of the cases.

In the author’s experience, most primary breast augmentations can be performed using fewer than 20 different available implants, as the width of implants ranging from 11 cm to 13 cm, with the most used implant width 12 cm ± 0.5 cm, with moderate to full projection, cover most patients’ desires and expectations.

By implementing an ABC protocol to any implant company’s matrix, as follows, you will be able to narrow down efficiently the number of implants to choose from ( Fig. 3.6 ):

• A.

  Decide on implant width based on measured ideal breast base width (IBBW).

• B.

  Decide on height of the implant if using anatomical implants based on chest configuration and upper pole breast volume; if you are using round implants move on to C.

• C.

  Decide on projection based on patient desire for volume.

The author’s general recommendation is that the surgeon should not compromise in the IBBW to shape a well-balanced breast. If a patient desires more or less volume this should be addressed by adding or lessening the projection of the implant. Different implants or sizers can then be tried on, under two tight elastic t-shirts. The t-shirts serve as a “second skin” and the objective is for the patient to get a feel for the volume more than shape. The author is also a strong believer in the benefits of 3D-imaging assisting the surgeon and the patient to reach a common goal regarding size and possibly shape. The author recommends all surgeons to become familiarized with the benefits of this technique.

The author truly believes that the importance of implant selection and volume assessment sometimes is underestimated. The cost benefit value of spending time sizing the patients before surgery cannot be emphasized enough. Size change is one of the most common reasons, if not the most common reason, for reoperations in breast surgery according to the annual report of the American National Breast Implant Registry (NBIR) 2020. Although size change is not considered a complication, it is a reason for reoperation and in the author’s opinion represents a complication in communication. Thus, the reoperation could have been avoided if implant selection would have been optimally addressed prior to surgery. Regardless of the reasons behind the size changes, the outcome always will be perceived as less favorable by the patient when compared with getting it right the first time.