What are the considerations and options for breast augmentation?

Breast Augmentation: Considerations and Options

Breast augmentation should be approached as a comprehensive process involving patient education, tissue-based planning, refined surgical technique, and structured follow-up to optimize outcomes and minimize complications. 1

Types of Breast Implants

Available Options

• Saline implants: Filled with sterile isotonic saline, these implants show visible deflation when ruptured as the saline is resorbed by the body 2
• Silicone implants: Contain fixed volume of silicone gel with varying viscosity between manufacturers 2
• Form-stable silicone implants: Also known as "gummy bear" implants 2
• Double lumen varieties: Combination of saline and silicone 2

Surface Types

• Smooth surface implants: Associated with lower complication rates
• Textured surface implants: Each manufacturer uses proprietary processes to create textured surfaces 2
  • Important safety concern: Most cases of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) are associated with textured implants 2

Surgical Techniques

Implant Placement Options

• Submuscular placement: Implant placed under the pectoralis major muscle

  • Provides better coverage and potentially lower risk of capsular contracture
  • May cause animation deformity with muscle contraction

• Subfascial placement: Implant placed under the fascia but above the muscle

  • Preserves natural breast movement
  • May provide less coverage for implant edges

• Dual-plane technique: Combines submuscular and subglandular placement

  • Modified approaches like the subfascial mini-muscle release dual-plane technique show promising results, especially for ptotic breasts and tubular deformities 3

Incision Approaches

• Inframammary fold: Hidden in the natural crease under the breast
• Periareolar: Around the edge of the areola
• Transaxillary: Through the armpit
• Transumbilical: Through the navel (less common)

Patient Selection and Preoperative Planning

Ideal Candidates

• Healthy individuals with realistic expectations
• Those seeking breast enhancement for cosmetic reasons or reconstruction

Relative Contraindications

• Smoking: Increases risk of complications for all types of breast reconstruction 2
• Obesity: Associated with higher rates of wound healing complications 2
• Patients with extensive in situ disease where extent of invasive carcinoma is not well-defined 2
• Poorly delineated tumors or those not clinically assessable 2

Potential Complications

Short-term Complications

• Infection
• Hematoma
• Wound healing issues
• Pain and discomfort

Long-term Complications

• Capsular contracture: Abnormal scarring around the implant
• Implant rupture: Requires regular monitoring
  • FDA recommends initial ultrasound or MRI 5-6 years after surgery, then every 2-3 years 2, 4
• Rippling and palpability: Most common complications 1
• Soft-tissue stretch: Can lead to implant malposition 1
• Hypersensitivity: May affect comfort 1
• BIA-ALCL risk: Rare T-cell lymphoma associated primarily with textured implants
  • Typically presents 8-10 years after implantation with peri-implant effusion 2

Informed Consent Considerations

The informed consent process is critical and should include:

• Detailed discussion of all potential risks, including BIA-ALCL
• Financial implications of possible revision surgeries
• Impact on future breast cancer screening (special mammographic views required) 4
• Effects on breastfeeding capability
• Expected aesthetic outcomes and limitations
• Need for long-term monitoring and possible future surgeries

Research shows that increased risk information decreases women's willingness to recommend breast augmentation, highlighting the importance of thorough preoperative counseling 5.

Breast Reconstruction After Mastectomy

For patients considering breast reconstruction after mastectomy:

• Consultation with a reconstructive surgeon should be offered 2
• Timing options include immediate or delayed reconstruction 2
• Reconstruction should not interfere with appropriate cancer treatment 2
• Options include implant-based reconstruction or autologous tissue methods:
  • Transverse rectus abdominis myocutaneous (TRAM) flap
  • Latissimus dorsi flap
  • Gluteus maximus myocutaneous flap 2

Follow-up and Monitoring

• Regular clinical examinations
• Imaging surveillance for silicone implants:
  • Initial ultrasound or MRI 5-6 years after surgery
  • Continued imaging every 2-3 years thereafter 2, 4
• Prompt evaluation of any breast swelling with ultrasound to rule out BIA-ALCL 4
• No specific recommendations for timing of implant removal or exchange in the absence of complications 4

Breast augmentation requires a systematic approach from initial consultation through long-term follow-up to achieve optimal outcomes while minimizing risks.