Breast Augmentation

Are breast implants associated with an increased risk for any particular forms of cancer? What is the likely course compared to patients without breast implants?

Several reports have suggested an association between breast implants (saline and silicone) and anaplastic large cell lymphoma (ALCL). Most cases of ALCL have been in textured implants, and tend to have a more indolent course and more favorable prognosis.

What is the impact of augmentation mammoplasty with autologous fat transfer on mammogram findings?

The impact is still uncertain to date. Fat necrosis is common after fat grafting and appearance on mammogram may range from lipid cysts and diffusely scattered calcifications to findings suspicious for malignancy such as clustered, branching microcalcifications or spiculated masses. These should be worked up and sometimes biopsied.

Are suspicious mammographic changes more likely to occur in breast reduction or breast augmentation with autologous fat transfer?

Breast reduction. In a blinded study, Rubin et al. found that masses requiring biopsy and scarring were more common in the reduction cohort than the fat grafting cohort.

When augmentation/mastopexy is performed for tuberous breast deformity, what complication is more likely to occur than in a patient without a tuberous breast?

Double bubble. This will occur if the native inframammary crease, which can be high and tight, does not fully expand after release. Over time, the lower pole skin stretches in response to the implant and this double bubble often improves spontaneously.

What factors are linked to a higher rate of reoperation in patients undergoing augmentation mammoplasty?

Pre-existing breast ptosis and simultaneous mastopexy. Furthermore, increasing grades of breast ptosis were linked with increasingly higher reoperation rates.

What is the correlation between incision site for augmentation mammoplasty and rate of capsular contracture?

IMF incisions have the lowest rate, while periareolar and transaxillary incisions have a 5 to 10 times higher rate of capsule-related complications.

What is the main factor that can contribute to adverse outcomes with simultaneous augmentation mammoplasty and mastopexy?

Large prosthesis (defined as greater than 350 mL) leads to greater adverse effects on vascularity and soft-tissue attenuation.

What is double capsule phenomenon and with what type of implants does it more commonly occur?

Late-onset seroma without signs of infection: a capsule layer is seen lining the pocket, which often contains a substantial volume of serosanguineous seroma fluid and a textured implant coated in a tight second capsule at the center of the pocket. More common with textured implants.

What is the most important factor in determining the maximum acceptable prosthesis size for a patient?

Breast base width.

What is the main arterial blood supply to the breast gland and nipple during submuscular augmentation?

Thoracoacromial; travels just deep to the pectoralis major muscle, supplying circulation to the overlying breast tissue and skin. Subglandular dissection disrupts the connection between the thoracoacromial vessels and the overlying breast, while submuscular dissection preserves it. Subglandular augmentation may be performed though capsular contracture rates may differ.

What is the appropriate intervention for implants appearing “too high” soon after augmentation?

Breast massage and breast band application. Breast shape following augmentation mammoplasty undergoes dynamic changes, as the skin envelope and pectoralis muscle stretch under the expansion pressure of the prosthesis.

What is the most common complication after cohesive silicone gel breast prostheses or “gummy bear” implants?

Capsular contracture (Baker III/IV): 9.8% for aesthetics and 13.7% for reconstructive procedures at 6 years. Rupture rate was 1.1%/3.8% and infection was 1.6/6.1%, respectively.

What factors are associated with increased risk of rippling of breast implants?

Textured implants (over twofold increase in one study), saline implants, subglandular placement, thin native breast tissue, ptosis.

What are the disadvantages of an augmentation performed in the subglandular plane as compared with subpectoral? What are the advantages?

Disadvantages: higher rate of capsular contracture, less satisfactory for mammography, and a higher risk of visibility, palpability, and a sharp transition in the upper pole.

Advantages: the subglandular plane allows increased control of inframammary fold position and shape and has little or no implant distortion with pectoralis contraction.

In which patients should subpectoral implantation be used with caution? Why?

Patients with significant postpartum atrophy, glandular ptosis, and significant native tissue volume loss. Higher risk of double-bubble deformity.

What is the significance of the “pinch test” for subglandular augmentation?

A minimum pinch test of 2 cm is recommended in the superior pole for adequate soft-tissue thickness to cover a subglandular implant. Soft-tissue thickness less than 2 cm increases risk of rippling and wrinkling with subglandular placement and thus, submuscular placement is recommended.

What is a “dual plane” augmentation?

A variation of the subpectoral augmentation designed to reduce the risk of double-bubble deformity. Subpectoral dissection is combined with a partial subglandular dissection that extends a variable distance above the inferior border of the pectoralis major muscle.

What is the most common complication of breast augmentation?

Capsular contracture, with rates reported between 0.5% and 30%.

What should the implant pocket be irrigated with to decrease the incidence of infection and capsular contracture?

Mixture of 50,000 U Bacitracin, 1 g cefazolin, 80 mg gentamicin, and 500 mL saline.

What is the rate of grade III/IV capsular contracture for primary breast augmentation with silicone implants at 6-year follow-up (Mentor, Inamed)? Rate for revision augmentation?

Mentor and Inamed published their 6-year data for gel implants and show contracture rates (grade III/IV) of 20% to 28% after primary augmentation and 34% to 40% after revision augmentation.

What is the capsular contracture rate (grade III/IV) for saline implants at 13-year follow-up?

Approximately 21%.

What is the main advantage of textured implants?

Implant-surface texturing reduces the contracture rate for subglandular prostheses.

No such advantage is seen in the submuscular position.

Compare contracture, leakage, and wrinkling rates between saline and silicone implants and what is the primary advantage of saline implants?

Both implants produce contractures, wrinkling, and leakage at similar rates. Rupture is easier to detect in saline implants.

What factors should be evaluated prior to performing an augmentation that can help to choose the proper implant size, reduce the reoperation rate, and produce a more predictable outcome?