Key points
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Understand what the patient wants and perform a careful pre-operative evaluation.
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Breast and torso dimensions and amount and thickness of breast tissue.
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Breast ptosis.
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Inframammary fold anatomy.
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Asymmetry (IES).
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Transmission of information to patient.
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Pre-operative management of patient expectations and informed consent.
Introduction
Consistently systematic and precise pre-operative patient evaluation, combined with informative patient teaching and pre-operative management of patient expectations is essential for the successful practice of aesthetic plastic surgery. This is especially true in breast augmentation surgery. The following pages outline an approach that has worked for me in minimizing complications and re-operation rates while producing a high level of patient satisfaction following breast augmentation. It is a methodical approach in the evaluation of the prospective patient seeking breast augmentation which includes a careful history with an emphasis on size concerns and a thorough physical examination entailing both an anatomic and aesthetic analysis resulting in an individualized surgical plan ( , , ).
As is true in all fields of medicine, the interac-tion with the patient begins with a careful history and physical examination. This also applies when approaching the prospective breast augmentation patient. Careful attention must be paid to the patient’s breast development, whether or not the breast development has been symmetric, the patient’s age at menarche and whether there is an appreciable change in breast size or sensitivity during the course of the menstrual cycle. A history of pregnancy is elicited from every patient and if they have been pregnant it is important to inquire about the changes in the breast following such pregnancies. Many patients are concerned by the loss of volume and the change in shape which may have occurred with pregnancy or breast feeding. If a patient has been pregnant I find it helpful to ask how the large the breasts became during pregnancy and whether the patient was comfortable with or liked the size of her breasts during her pregnancy.
Carefully noting the patient’s opinion regarding breast settling or ptosis is important. When appropriate, suggestions regarding breast ptosis correction in conjunction with breast augmentation can be made by the plastic surgeon. It is important for the plastic surgeon to inquire about any lumps or masses that the patient may have had in either breast during the course of her lifetime and what treatment was given for this problem. Specifically, it is important to determine exactly what the diagnosis was and how it was resolved. In patients who are older than 35 years of age, the physician must inquire whether the patient has had a mammogram, and if so, the results of the study must be known. I ask the patient whether the mammograms have been normal and will often request that the report be sent to my office for inclusion in the patient’s chart. If there is any question about a previous mammogram I will request that the films be sent to my office. I find it helpful to personally review these mammograms with the help of a radiologist. If a patient has not had a mammogram by the time they have reached 35, one should be ordered and the results verified prior to a planned surgical procedure ( ).
Patient evaluation
Important aspects of the pre-operative physical examination
The plastic surgeon performing breast augmentation must perform a systematic examination of the breasts on each patient. The visual, tactile and artistic senses as well as communication skills of the plastic surgeon all come into play during this essential part of the pre-operative evaluation process ( , , ). The surgeon must note the general appearance of the breasts, scanning them for symmetry in terms of contour, fullness, nipple areola position, position of the areola complex relative to the infra-mammary fold and the amount of ‘skin show’ peripheral to the nipple in all directions ( Figure 1.1 ). The relationship of the breast to the mid-sternal area (cleavage) and the position of the breast relative to chest wall structures is also noted. Examine the anterior and posterior aspect of the patient’s torso looking for musculoskeletal abnormalities such as scoliosis and soft tissue abnormalities that can produce asymmetry(ies). Both obvious and subtle asymmetries are noted.
As alluded to previously, I find it helpful to measure the dimensions of the breast including the base width ( ), height (i.e., the extent of upper pole fullness when the breast is gently compressed against the chest wall) and various distances of the breast architectural features from a fixed point on the torso ( Figure 1.2 ). Most frequently, I measure the distance from the nipple to the supra-sternal notch on each side followed by the distance of nipple to the IM fold in the mid-meridian of the breast and also the distance from the inferior aspect of the areola complex to the IM fold. I record all these measurements on a breast diagram ( Figure 1.2 ) and incorporate the information on a worksheet ( ) compiled for use in breast augmentation and kept in the patient’s chart ( Figure 1.3 ).
The inframammary fold (IMF) is perhaps THE critical structure in determining breast shape and lower breast pole aesthetics. It is also a key indicator of breast abnormalities, developmental problems and asymmetries. The inframammary fold is formed by a condensation of connective tissue arising as a coalecence of anterior and posterior leaves of the superficial fascia which is an extension of Scarpa’s fascia in the abdomen which inserts into the dermis at the lowest aspect of the inferior pole of the breast. There have been many anatomic studies on the anatomy of this structure and I believe the most informative is that published by . The inframammary fold outlines an arc beginning near midline and continuing laterally where it extends to the lateral aspect of the breast and its juncture with the lateral chest wall at the anterior axillary line ( , , ).
The surgeon should evaluate the fold for its degree of tightness, position on one side of the chest relative to the opposite breast and for any degree of asymmetry. Normally the fold is roughly symmetric when comparing both breasts. Asymmetries in the fold are not uncommon ( Figure 1.4 ) and must be noted by the surgeon and pointed out to the patient pre-operatively. Any flattening or straightness in the curve at any point of this arc may indicate a form of a constricted breast ( Figure 1.4A ). It may be unilateral or bilateral. When it occurs unilaterally it may not be possible for the breast plastic surgeon to correct this and thus the asymmetry noted pre-operatively will be present post-operatively. A fold that is high and ‘tight’ ( Figure 1.4C ) presents potential difficulties when the operative plan entails lowering the fold to accommodate a large implant and in my experience is a predictor of an increased chance for re-operation following breast augmentation ( ).
The surgeon should note the thickness, distribution and elasticity of the breast parenchyma ( ). The upper pole breast thickness can be determined by grasping the parenchyma 4 cm above the areola in a maneuver described by Tebbets as the ‘pinch test’ ( Figure 1.5 ) ( ). A thickness of at least 2 cm is necessary for the draping the implant if sub-glandular placement of the implant is contemplated. Distances from the nipple to IMF are measured ( Figure 1.6A ). Other maneuvers to stretch the breast tissue in a superior and anterior direction are helpful in evaluating the potential effects of the implant on the breast tissue ( Figure 1.6B,C ). Similarly evaluation of skin condition of the breasts is noted with the surgeon keying into the elasticity, the presence of striae and existence of previous scars on the breast skin. Pre-existing striae may become worse following breast augmentation, and a lax skin envelope indicates that the skin will play no role in helping to support a breast implant.
Implant position is determined by tissue factors, degree of ptosis and patient desires. Partial sub-pectoral positioning is the most common site of implant placement in my practice. It provides the maximum thickness of soft tissue padding and thus concealment for the implant, is associated with a lower chance of capsular contracture as reflected in every study in the literature, and it provides the best possible mammograms. This latter benefit of facilitating mammographic evaluation of the breasts cannot be understated. Minimal degrees of breast ptosis are better treated with sub-glandular implant placement. Sub-glandular placement allows a minimally ptotic breast to be re-distributed over the entire implant. The dual plane approach allows redistribution of the lower pole tissue over the implant and is helpful in cases of mammary pseudo-ptosis ( ).
It is true that almost no woman’s breasts are perfectly symmetric ( , ). That is to say a careful physical examination will almost always reveal some element of breast asymmetry ( , ). It is essential that the plastic surgeon point out asymmetries to the patient pre-operatively ( , , ) as these will remain after surgery. Following augmentation of the asymmetric breasts, the overall breast appearance is usually markedly enhanced and the patient will look right past them. Essentially, this is always true if the patient is made aware of the asymmetries prior to surgery. The adage that ‘an explanation prior to surgery is an explanation, an explanation after surgery is an excuse’ is true in most areas of aesthetic surgery.
Many elements of asymmetry are illustrated by the patient seen in Figure 1.7 . Her pre-operative evaluation revealed multiple breast asymmetries including breast volume, infra-mammary fold level, breast contour with definite difference in the infero-lateral contour, nipple position, nipple inclination, and areola size ( Figure 1.7A ). The patient underwent the partial retro-pectoral placement of 12.3 cm diameter 360 mL smooth walled moderate profile implants. Note that all of the pre-operative asymmetries are present post-operatively but the breasts show more fullness and overall aesthetic enhancement ( Figure 1.7B ). Wide set breasts have a wide cleavage ( Figure 1.8 ). This anatomic condition cannot be changed by implants and the cleavage will remain wide after surgery.
Discussion about breast size and implant selection
It is interesting to note that patients have different ideas concerning what is most aesthetic in a breast augmentation and many are interested in obtaining a certain look which they individually feel is most aesthetic. This is illustrated by the fact that many patients bring in pictures pre-operatively indicating how they want their breasts to appear post-operatively. This can be helpful to the surgeon. However, the surgeon must decide if the patient’s desires can or should be realized.
Concepts about breast attractiveness relative to size are different in different cultures with women in Europe and South America generally desiring less breast volume enhancement from a breast augmentation. I try to listen very intently to every idea and intention a particular patient has about her perceived post-operative size. As previously mentioned, I have come to understand that what patients want and find desirable is often very different than what the plastic surgeon considers to be an aesthetically desirable result. After my breast analysis which focuses on an analysis of breast dimensions and tissue characteristics and speaking with the patient I can usually narrow the implant choice to either one or two implants.
I perform a final cross-check of the probable implant selection by reviewing photographs brought in by the patient at my request ( ). These are images which can be downloaded from a variety of websites containing pre- and post-operative images of actual breast augmentation patients (not models) ( Figure 1.9 ). These provide an important insight into a particular patient’s desires and expectations for both volume and shape following breast augmentation. Most often it coincides with my choice of an implant but occasionally there are surprises when a patient wants to be either larger or occasionally smaller than my analysis and communication with the patient has led me to believe. I find, however, that the process of a patient’s bringing in photos is helpful to me and more so than having patients place implants in a bra over the surface of their breasts. I do not subscribe to this practice but would suggest it is known for surgeons to ‘go up one size in the implant’ to compensate for the compression effect of the breast and muscle tissue on the implant.
Although the topic of implant selection is covered in other chapters of this volume suffice it to say the pre-operative planning and implant selection depend to a significant degree on patient anatomic factors including breast dimensions, torso dimension, degree of ptosis, tissue elasticity, and pre-existing asymmetry. In my practice, implant selection is governed mostly by anatomic surface relationships, as well as breast and torso dimensions. The ‘paradigm shift’ of emphasizing correlating implant dimensions ( ) to important anatomic dimensions of the breast and torso was a positive benefit of using saline implants almost exclusively for breast augmentation from 1992 until 2006 in the United States.
The most important dimension is the base width of the breast ( Figure 1.2 ) or the distance from the area immediately lateral to the lateral edge of the sternum to the mid-axillary line. This distance determines the largest implant which can be placed especially if a round implant is selected. The center of a round implant should be positioned beneath the nipple. If the implant has too great a diameter (i.e., is too large) then the breast will elongate vertically or produce an abnormal horizontal contour. A helpful rule of thumb is that when using a round implant the largest radius which should be used is equal to the distance from the nipple to the immediate parasternal area. This is because the tissues between the nipple and the parasternal area are fixed, i.e., the distensibility of the breast tissue there is less than it is laterally in the area between the nipple and lateral breast. The height of the implant is also important but since the IM fold is often lowered the accomodatable height can vary. The distance from the nipple to the lateral silhouette of the breast on AP is also variable due to the distensibility of those tissues as mentioned above. Therefore, the horizontal distance from the nipple to the parasternal region represents the greatest implant radius that should be used. I will generally choose an implant which is smaller in dimension than this distance.
After carefully recording these dimensions I will consult various implant charts provided by the manufacturers to select an implant which will best satisfy the patient’s desires and ‘fit’ her anatomy. If there are other anatomic considerations such as petite or small stature, or narrow torso, it is often desirable to select an implant with more volume for a given base dimension. In such a patient, a high profile implant (one with greater projection and volume for a given base diameter) may be helpful. Such implants are very helpful in patients who place a premium on a large volume in the face of smaller breast and torso dimensions. Alternatively, a shaped textured implant can be used. These implants are designed with variable heights and volumes for a given base width and they give the illusion of greater projection and volume for a given base diameter dimension ( Figure 1.10 ). I will use a shaped implant with a relatively short vertical dimension in patients of small stature who desire a very full breast. Conversely, I have found that shaped implants which have a long vertical dimension are helpful in the very tall patient (more than 6 feet in height) who requires upper pole fullness as part of their augmentation.
