Case 35 Breast Augmentation
35.1 Description
Hypomastia: Small A cup breasts with mild asymmetry
Right inframammary fold is slightly higher than the left side
Right nipple is slightly higher than the left nipple
35.2 Work-Up
35.2.1 History
Age, medical comorbidities, anticoagulant use, and smoking history
Pregnancy/breastfeeding history; plans for future childbearing
Personal history of breast disease and/or procedures, prior mammography or ultrasound
Family history of breast cancer
Current bra size and desired breast size
Motivation for surgery
35.2.2 Physical Examination
Evaluate breast shape, skin quality, and adequacy of tissue envelope (e.g., upper pole pinch thickness)
Identify any asymmetries (volume, nipple–areola complex, inframammary fold position) and thoracic wall abnormalities
Palpate for breast masses or axillary lymphadenopathy; identify skin dimpling or nipple discharge
35.2.3 Diagnostic Studies
American Cancer Society guidelines for clinical breast exam (CBE) and mammography should be followed
Clinical breast examination every 3 years for women aged 20 to 39 years
Breast examination annually for women aged 40 and older
Yearly mammograms for women aged 40 and older
Breast masses or lymphadenopathy discovered on physical examination should be evaluated before augmentation
35.3 Patient Counseling
An effective consultation establishes an accurate understanding of the patient’s goals from the surgeon’s perspective, and establishes realistic expectations of the final result from the patient’s perspective.
Informed consent must include management of patient expectations and thorough discussion of existing asymmetries, potential complications, rupture screening recommendations, rates of revisional surgery (approximately 20%), responsibility for cost of revisions, and eventual need for implant exchange or removal
Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)
All patients being evaluated for breast implants should be informed of the risks and common presentations of BIA-ALCL.
Clinical experience has shown that this process is generally well received and is not disruptive to patient interactions.
When counseling on implant options, patients should be informed that BIA-ALCL is a predominantly textured implant-associated disease, although it is premature to conclude at this point that it cannot occur in smooth implants.
Both silicone (57%) and saline (43%) implants have been linked to BIA-ALCL with no specific predilection.
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