The incidence of reoperative surgery following the placement of an implant, for either breast reconstruction or breast augmentation, is significant. This has been documented by numerous published studies.¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶ and ¹⁷ The reoperation rate at 5 years for breast augmentation—documented by Gabriel et al.⁷ in a study of 1,800 patients at the Mayo Clinic—was 12% at a 5-year follow-up, while 34% of patients who underwent implant placement for breast reconstruction required reoperation during that same time period. Additional studies have found reoperation rates of 15% to 20% following silicone gel breast augmentation.12,13 At the height of the concern about safety issues regarding breast implants in the early 1990s (popularly termed the “breast implant crisis”),³ this rate was even higher because of the number of women requesting removal of their implants.

After April of 1992 plastic surgeons in the United States were confined to the exclusive use of saline implants for primary breast augmentation.³ Data relating to this experience were collected by various authors and the implant manufacturers.¹³, ¹⁴, ¹⁵, ¹⁶ and ¹⁷ Once again, when one surveys the incidence of reoperation in this group of patients, the risk during the first 3 to 5 years is high. The Mentor Corporation,¹⁶ in a prospective premarket approval study, reported an incidence of reoperation in 13% during the first 3 years following saline implant breast augmentation. Similarly the McGhan Corporation in its study (AR95)¹⁷ reflected a 21% risk of reoperation at 3 years. A benchmark prospective, longitudinal study of saline breast implants published¹⁴ and updated¹⁵ demonstrates a 26% incidence of reoperative surgery within 5 years of saline implant placement for breast augmentation.

Additional studies, including that of Young et al.,¹³ disclose a high rate of reoperation in the form of explantation (24%) within 7 years of breast augmentation surgery, with many patients requiring more than one explantation. The most common reasons cited for explantation in these studies include capsular contracture, rupture or deflation, asymmetry, inadequate size, and patient request for implant change.¹³

A new source of data on the outcome of saline breast implant placement is the Saline Breast Implant Registry (NaBIR), which was begun in 2000,¹⁸ largely through the efforts of Dr. V. Leroy Young in conjunction with the Plastic Surgery Educational Foundation. It is a confidential registry of data submitted by plastic surgeons on saline implant placement for either breast augmentation or reconstruction that allows prospective tracking and comparison of results in an identifiable cohort of patients. The data compiled thus far again indicate that the reoperation rate for explantation is significant (15.4%) within the first 4 years following surgery.

From the foregoing studies it is apparent that reoperation following a previous breast augmentation is common. Furthermore, it is my opinion that the revision rate is too high for an elective cosmetic surgery procedure.

A significant portion of these reoperations are attributable to implant-related factors and therefore they are probably not preventable with the implants that are currently available for use. However, problems leading to early revisions (e.g., those due to size change and operations done to treat implant malposition and some asymmetries) are most likely due to inadequate preoperative communication with the patient, improper analysis of patient anatomic features, and incomplete preoperative planning and/or errors in surgical technique. I am firmly convinced that the rate of reoperation for the conditions just mentioned can be reduced by better preoperative planning and more consistent technical performance of the operation. Said another way, it seems apparent to me that such problems are best addressed by prevention. This view is shared by other authors as well.¹⁹,²⁰

Toward this goal, I have adopted a methodical approach to the evaluation of the prospective patient seeking breast augmentation. This includes taking a careful history with an emphasis on size concerns and conducting a thorough physical examination with an anatomic and aesthetic analysis, which results in an individualized surgical plan for implant selection and the surgical approach. The procedure is performed with an awareness of the patient’s particular anatomy using mainly the electrocautery with minimal gentle blunt dissection of the lateral pocket as described. The goal is to achieve precise pocket dissection that will fit the chosen implant. This approach has been successful in my hands from the standpoint of decreasing the incidence of short-term problems related to doctor-patient communication (implant selection), inadequate planning, and technical errors. The details of this approach are described in the following section. Subsequently, my approach to revision of breast augmentation is discussed.

As in all of medicine, the interaction 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 chief complaint or desires regarding the operation, her anatomic features, and her breast development. The latter is investigated regarding whether the breast development has been symmetric. The patient’s personal history of breast problems, e.g., pain, menstrualcycle-related breast variations, and history of breast
masses, with any family history of breast cancer, is thoroughly investigated.

It is important to inquire about any lumps or masses that the patient may have had in either breast during the course of her lifetime and what the treatment of these was. 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 about whether the patient has had a mammogram, and if so the results of the study must be known. I find it helpful to personally review these mammograms—often with the help of a radiologist. If the patient has not had a mammogram by this age, one should be ordered.

It is very important for the physician to understand, in as much as is possible, the patient’s desires relating to breast size. If a patient has been pregnant, I find it helpful to ask how large the breasts became during pregnancy and whether the patient was comfortable with or enjoyed the size of her breasts during her pregnancy. To help me better understand the patient’s desire for size and appearance of the breast following surgery, I prefer to have the patient bring in pictures of normal patients (not models) with similar body types who have an appearance that they find attractive and desirable. This gives me an insight into the look that the patient is after. Such photos are available on a variety of websites (Fig. 3-1).

Similarly, in the setting of a previous pregnancy, it is important to inquire about the changes in the breast following such pregnancies. Many patients are bothered by the loss of volume and the change in shape that has occurred. Carefully noting the patient’s opinion regarding breast settling or ptosis is important, and when appropriate, suggestions regarding breast ptosis correction in conjunction with breast augmentation should be made. I am increasingly performing a mastopexy in conjunction with an augmentation in this population of patients, especially as part of a revision procedure. If the plan entails a mastopexy, I believe that it is critical to discuss the position of scars, the fact that they will be permanent, and the fact that recurrent breast ptosis is part of the picture with every mastopexy—including augmentation mastopexy. I find that this operation carries a higher risk of complications than either of these procedures performed separately.

Systematic examination of the breast is carried out as described in Chapter 2. The surgeon should note the general appearance of the breasts, scanning them for symmetry in terms of contour, fullness, nipple areola position, and the position of the breast relative to chest wall structures. 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 (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. Most often I find it helpful to measure the distance from the nipple to the suprasternal notch (SSN) on each side, followed by the distance of nipple to the inframammary (IM) fold in the midmeridian of the breast and also the distance from the inferior aspect of the NAC to the IM fold. I record all these measurements on a breast diagram or a worksheet I use for breast augmentation in the patient’s chart (Fig. 3-2).

After performing a complete and systematic examination, I discuss with the patient the potential incisional and implant position options. The incisional approaches I use are the IM (60%), transaxillary (30%), and periareolar (10%) (Fig. 3-3). All of these incisional approaches can work well in the appropriate situation and usually leave inconspicuous scars. Patients often have a preference for which scar position they would like, and it is usually possible to accommodate their wishes. Exceptions would be grade II or greater ptosis in a patient who desires a transaxillary breast augmentation.

The choice of implant is patient specific. Most patients who undergo breast augmentation in the United States seek a breast volume increase of two cup sizes.¹ Concepts about breast attractiveness relative to size are different in different cultures, with women in Europe²¹ and South America²¹ in general 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 postoperative size. 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. As previously mentioned, reviewing photographs brought in by the patient can yield an important insight into a particular patient’s desires and expectations for both volume and shape following breast augmentation.

Preoperative planning and implant selection depend to a significant degree on patient anatomic factors including breast dimensions, torso dimension, degree of ptosis, preexisting asymmetry(ies), and tissue quality, including elasticity, thickness, and ability to stretch.²⁰ In my practice implant selection is governed mostly by anatomic surface relationships, and I key into breast and torso dimensions. The most important is the base width (Fig. 3-2) of the breast, or the distance from the area immediately lateral to the lateral edge of the sternum to the lateral silhouette of the breast. This distance determines the largest base width of the implant that 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 (is too large dimensionally), 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 that should be used is equal to the distance from the nipple to the ipsilateral parasternal take-off of the breast (Fig. 3-4). This is because the tissues between the nipple and the parasternal area are fixed. The height of the implant is also important, but because the IM fold is often lowered the accommodative height can vary. The distance from the nipple to the lateral silhouette of the breast on anteroposterior (AP) view is also variable due to the distensibility of those tissues. Therefore, the horizontal distance from the nipple to the parasternal region represents the greatest implant radius that should be selected when a round implant is used. I will generally choose an implant that is smaller in dimension than this distance.

The distance from the midclavicular point to the nipple and the distance from the SSN to the nipple are also important dimensions, and they are recorded on the preoperative worksheet (see Fig. 3-2). After carefully recording these dimensions, I consult various implant charts provided by the manufacturers to select an implant that will best satisfy the patient’s desires and fit her anatomy (Fig. 3-5A-B).

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 (Fig. 3-6A,B). 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 (Fig. 3-6C). I use a shaped implant with a relatively short vertical dimension in patients of small stature who desire a very full breast.²² Conversely, I have found that shaped implants that have a long vertical dimension may be helpful in the very tall patient (greater than 6 feet in height) who require tapered upper pole fullness as part of their augmentation.

Although most plastic surgeons acquire the majority of their individual experience with a certain style or type of implant (I prefer a smooth round implant for most patients seeking breast augmentation), the surgeon must have experience with and facility using various types of implants. This permits using the most individualized approach with each patient.

The two alternatives for implant position are either the subglandular or the submuscular space (Fig. 3-7A-B). The choice, again, depends on the patient’s anatomy, surgeon analysis, and a combination of patient and surgeon preference. Placing the implant in the subglandular space simplifies the procedure in terms of the dissection, is associated with less postoperative discomfort, and generally results in a quicker recovery.²³ This position for the implant is especially good for patients who have glandular, grade I, and some mild forms of grade II mammary ptosis. For the surgeon to use this position, the patient must have sufficient upper pole breast tissue to cover or camouflage the edges of the implant. I determine the adequacy of the tissue in the upper part of the breast by using the pinch test as described by Tebbetts.²² I too believe that there should be at least 2.5 cm of tissue in the upper pole of the breast to adequately conceal a subglandular implant (Fig. 3-8). If there is not, it is best to use the subpectoral position for implant placement—especially if a saline implant is selected because this type of implant has a definite predilection for visibility and palpability. The major disadvantages of the subglandular position of an implant are that there is an increased risk of capsular contracture²⁴,²⁵ and that mammograms are less sensitive,²⁶ i.e., more of the breast tissue is hidden. Finally, the dissection to place an implant in the subglandular space results in greater decrease in the blood supply to the remaining breast parenchyma with the division of many perforating vessels from the pectoralis major muscle (PMM; Fig. 3-9A,B).

In this era of saline implants, by far the most common position is the submuscular or, more precisely stated, a partial retropectoral position for the implants (see Fig. 3-7B). This is because such positioning will maximally camouflage any type of irregularity related to the implant edge or changes in implant shape related to the distribution of the sterile saline filler substance within the implant. In addition, subpectoral placement is associated with a decreased incidence of capsular contracture regardless of implant type.²⁴ Finally, the subpectoral position affords the best possible breast surveillance in terms of postoperative mammograms.²⁶ This may be an important consideration for many patients, and increasingly I find it to be a particular advantage. The dissection is a little more technically demanding, and it most often involves the release of the origin of the PMM from the fifth and sixth ribs (Fig. 3-10). After the release of this portion of the muscle, the inferior aspect of the breast implant sits beneath the lower pole of the breast, or even beneath the subcutaneous tissue in those patients who have a lowering of their previous IM fold. There is also more postoperative discomfort associated with this approach than that seen following subglandular placement of a breast implant.

In my current practice the incisions I offer to patients are the inframammary (IM), infra-areolar, and axillary. I currently do not perform transumbilical breast augmentation.

The IM incision is the most commonly used and most versatile of the incisions used for breast augmentation. This is reflected in my practice and by data recorded in NaBIR.¹⁸ It provides direct visualization of the subglandular and subpectoral planes and offers the most direct approach for managing any problems in the lower pole such as IM fold asymmetries. This incision has a tendency to ride up on the implanted breast as the implant settles, and therefore it should be positioned adequately low or approximately 1 to 2 mm below the intended level of the new IM fold. A careful three-layered closure of the wound, which includes the tissue adjacent to the implant, the deep dermis, and an intracuticular apposition of the skin wound, is routinely performed.

The infra-areolar incision is also commonly used. It also affords excellent access to the lower pole of the breast, whereby the surgeon can address asymmetries or treat discrepancies or constriction of the IM fold. It can be incorporated into a periareolar incision, thereby making it an excellent choice for cases that are likely to include an augmentation mastopexy. It is also very useful for treating patients with a constricted breast deformity (Fig. 3-11) because it allows a setback of the pseudo-herniation of the NAC, which is a salient feature of that deformity. The incision should be placed in the junction of the more darkly pigmented areolar skin and adjacent breast skin. In this position it is less conspicuous. Placing it within the areola itself may result in visibility due to potential hypopigmentation of the resulting scar. Access to the subglandular or subpectoral space is attained by dissecting directly through the breast parenchyma or by inferior elevation of a breast skin flap above the breast fascia and entrance into either of these planes from below (Fig. 3-12A,B). I prefer to dissect through the breast parenchyma as this route provides a direct exposure to either plane. The incision often yields excellent cosmetic results, but it may result in a slightly greater chance for decreased nipple sensibility.

The transaxillary approach to breast augmentation avoids a scar on the breast, and in my practice it is a popular approach for young unmarried women. I believe that the incision should be positioned transversely, and I generally tend to place it in or just above the highest skin crease in the axilla. It should be kept posterior to the posterolateral edge of the PMM and anterior to the latissimus dorsi muscle (Fig. 3-13A,B). The incision should be limited to between 3.0 and 3.5 cm. With this approach the skin should be undermined for a distance of 2 cm in both an anterior and inferior direction, and dissection through the clavipectoral fascia gives access to the subpectoral space. The resulting scar is almost always inconspicuous by 1 year following surgery. There is an incidence of numbness and paresthesias involving the upper inner arms related to retraction of or injury to the intercostal brachiocutaneous nerves, but in my experience this is less than 5%. In every case of transaxillary breast augmentation I inform the patient preoperatively that should she require re-exploration for bleeding or other problems, this will usually require another incision on the breast, either in the IM fold or infra-areolar area.

Information about the options just discussed is presented to the patient in an interactive format to encourage active participation in the decision-making process on the part of the patient. During this time instructions regarding postoperative care are also given to the patient. Finally, a detailed enumeration of the potential risks and complications concerning breast augmentation is presented to the patient. During this discussion we emphasize that a breast implant will in all likelihood not be a lifetime device and that the two most common inherent risks following this operation are those of capsular contracture and the need for reoperative surgery on the breast(s) at some point in the future.⁷ A sample of the consent form I use for primary breast augmentation is shown in Appendix A of this chapter Finally, we discuss cost implications regarding unplanned reoperative surgery after breast augmentation (surgeon’s fees, facility charges, and anesthesia fees), both in the rare circumstance of surgery done immediately following the procedure (e.g., to drain a hematoma) or surgery undertaken at a later date.

Once decisions about the type of implant, position of the implant, and selection of incision have been made, the patient must decide whether to proceed with surgery. I find that there is a high patient sign-up rate (>80%) for patients I see in consultation for breast augmentation.

There is no doubt in my mind that careful preoperative planning and precise, consistent pocket dissection are important in every breast augmentation. Furthermore, I strongly believe that the incidence of immediate postoperative and short-term problems (implant malposition and palpability, breast asymmetry), and perhaps long-term problems as well (implant rupture or deflation and even capsular contracture), following breast augmentation can be reduced by individualized surgical planning and consistent technique.

The patient is carefully marked before surgery in the upright position to ensure precise pocket dissection and placement of incisions. Outlines of the existing IM fold and breast base width are inscribed on the skin. Next, the precise position of implant placement is noted (Fig. 3-14A). If the IM fold is to be lowered, the exact extent of this lowering is noted (Fig. 3-14B). I do not dissect the largest possible pocket because this may predispose to implant malposition. To create a more precise pocket I next outline the extent of superior pocket dissection. I find it helpful to have the patient compress her breast gently against the chest wall, and in this way the most superior aspect of the breast is apparent (Fig. 3-15). To limit the possibility of excess medial dissection I next draw a vertical line in the middle of the sternum. Then I draw two additional lines, one on either side of this first line 1.5 cm lateral to it over the lateral sternal area (Fig. 3-16A). These lines denote the medial-most extent of the dissection (Fig. 3-16A). I do not dissect medial to them. I have found that this will minimize the possibility of creating medial implant malposition (symmastia if it is seen bilaterally). The midaxillary line on the lateral chest wall should be noted. This vertically oriented line
lies midway between the lateral border of the PMM and the anterior edge of the latissimus dorsi muscle, which can be easily appreciated in most patients (Fig. 3-16B). I do not dissect lateral to this point. Limiting the extent of lateral pocket dissection is an important factor in limiting the likelihood of lateral implant malposition.

Planning the surgery in this way provides a guide to precise pocket development. In my hands the combination of planning and consistent surgical technique optimized postoperative breast symmetry and has limited the occurrence of breast asymmetry and implant malposition and early reoperations related to them.

The 1-year postoperative results of the patient noted in Fig. 3-14 on AP and oblique views is illustrated in Fig. 3-17 A, B).

Dissection of the pocket for implant insertion should be done in a gentle manner with attainment of meticulous hemostasis. I perform almost all of the dissection under direct vision with the electrocautery with the exception of the lateral aspect of the pocket, which is performed last with gentle digital dissection (Fig. 3-18) after the sizer has been positioned. Minimal, blunt gentle digital dissection minimizes injury to the lateral sensory nerves and the possibility of lateral implant subluxation (Fig. 3-18) while allowing me to maximize the medial fullness or cleavage. The lateral sensory nerves very often can be palpated and/or directly visualized. Most recently when I have visualized the nerves through an IM incision, I have occasionally performed this lateral pocket dissection with the electrocautery, dividing tissue adjacent to the nerves with minimal danger of injuring them.

When using a saline implant sizer I inflate this device with air in situ using a one-way valve. The maneuver is carried out with the patient placed in the sitting position at 90 degrees on the operating table (Fig. 3-19). Most often I use implant sizers to assess the adequacy of pocket dissection and breast contour rather than to establish which size implant I will choose. This decision is usually established before the operation.

The subglandular space is easily dissected through either an IM or infra-areolar incision using a headlight or lighted retractor. I perform the dissection inferior to medial to superior according to the preoperative skin markings. The lateral dissection is initially limited. I then place an OpSite dressing on the skin to eliminate contact of the implant with the patient’s skin and associated skin flora (Fig. 3-20A). The sample sizing implant or the implant to be used for the procedure is inserted through an incision made in the OpSite (Fig. 3-20B). Before inserting this device I analyze this implant sizer for its base dimension by measuring it. In addition, both pockets are irrigated with a solution containing 50,000 IU of bacitracin, 500 mg cefazolin (Ancef), and 80 mg gentamicin in 1,000 cc of sterile saline intravenous (IV) fluid.²⁷

The symmetry of the breasts, including implant position and inferior level of the implants, is checked with both implants in place while exerting gentle downward pressure on the upper poles of the breast (see Fig. 3-19). This maneuver is very helpful in minimizing asymmetries of the IM-fold level of the augmented breasts.

When I am completely satisfied with the implant position and breast appearance, I perform a three-layer closure of the wound as described earlier, applying a circumferential dressing consisting of both a Kerlix (Tyco Healthcare Group, Mansfield, Mass) roll application and Ace (Becton Dickinson, Franklin Lakes, NJ) wrap. The dressing remains in place for approximately 3 days, at which time the patient is taken out of her dressing and switched to a sports bra. Bra support of the breasts is maintained for 1 month following surgery. When an IM incision is used, I request that patients refrain from using an underwire bra for 3 months to minimize any adverse effect on the incision.

The subpectoral space can be developed using any of the incisions described earlier. From the IM approach I identify the lower pole of the breast tissue and gently sweep it superiorly using the electrocautery set to the coagulation mode. This allows identification of the lateral border of the PMM, and the plane beneath it is easily entered under direct visualization (Fig. 3-21A). This plane is developed with electrocautery dissection directed superior-medially toward the NAC. A narrow Deaver retractor is then inserted and the remainder of the dissection is performed with the electrocautery. The origins of the PMM are released on its deep surface along the length of the lower aspect of the breast proceeding from lateral to medial, establishing the desired inferior position of the implant pocket. The PMM is completely released in most cases to the parasternal area (Fig. 3-21A). The exception to this is the exceedingly thin patient in whom the muscle is released but the pectoralis fascial layer is maintained intact by gently stretching this layer with blunt dissection. This provides an additional layer of tissue to pad the implant in the lower breast. More important, this layer may help to support the weight of the implant. Along the lateral sternal area the PMM is not divided but rather it is attenuated on its deep surface (Fig. 3-21B). Releasing the muscle here can produce an abnormal contour, often leading to a step-off along the lateral sternum that is difficult to correct.

Instead the medial PMM is attenuated on its deep surface (Fig. 3-21B). This is accomplished by scoring the muscle on its deep surface with the electrocautery set to the coagulation mode. The deep muscle surface is gently touched in a doting-type fashion. The depth of the dissection within the deep surface of the muscle is usually 3 to 5 mm. This attenuation of the PMM allows a favorable drape over the implant and produces the best possible cleavage when the subpectoral position is chosen for breast augmentation. I believe that detaching the medial or parasternal PMM should be avoided, and this view is shared by others.²⁸ Next, the superior extent of the pocket is established. The lateral dissection is initially limited. The dissected pocket is then irrigated with the antibiotic solution noted earlier. A sizer is placed as noted earlier, and the final adjustments to the lateral implant pocket are completed with the patient in the sitting position using gentle digital dissection (see Fig. 3-18). Very often the surgeon will feel the lateral intercostal nerves as transverse bands. These can be slightly stretched, but they must be preserved intact. Once again, the lateral dissection should never be carried posterior to the midaxillary line. This line is also routinely drawn on the patient’s skin preoperatively. The final breast appearance is checked with sizers in both implant pockets, and if it is completely satisfactory, implants are inserted and then the incision is closed in three layers.

The subpectoral space can be developed through the infra-areolar incision by dissecting through the breast parenchyma and splitting the medial PMM in the direction of its fibers. This provides immediate and excellent access to the underside of the PMM, and release of its origin from the fifth and sixth ribs can be accomplished as outlined in the preceding paragraph. The remainder of the procedure is as outlined earlier.

When using an axillary incision, standard markings are used (Figs. 3-13A and 3-22A). I currently prefer using endoscopic assistance to perform the PMM release from its origin on the fifth and sixth ribs inferiorly as opposed to using blunt dissection. As noted earlier, after the incision is made the skin is undermined for a distance of 2 cm, and then the dissection is deepened through the clavipectoral fascia and the lateral border of the PMM is noted. The muscle fibers themselves are not exposed. The interval between the PMM and pectoralis minor muscle is directly visualized, and the subpectoral plane is developed by gentle blunt dissection with an Agris-Dingman dissector inferiorly toward the origin of the PMM. A special balloon dissector is inserted and inflated to create the optical
cavity. I have found that a sample sizing implant works equally well for this maneuver. Next the endoscope is inserted, and operating through the same transaxillary incision the origin of the PMM is visualized (Fig. 3-22B). This technique provides a controlled release of the muscle (Fig. 3-22C) and can also facilitate hemostasis. The final inferior dissection to establish the inferior aspect of the implant pocket is done with the Agris-Dingman dissector. After completing the dissection of both pockets, the space is irrigated with a solution containing 50,000 IU of bacitracin, 500 cc cefazolin (Ancef), and 80 cc gentamicin in 1,000 cc of sterile saline IV fluid²⁷ and the sample sizing implants are placed. Symmetry between the breasts is checked with the patient in the sitting position. I find that it is helpful to gently compress the upper poles of the sizers to ensure symmetry of the lower aspect of the breasts (see Fig. 3-19). When the appearance of the breasts is completely satisfactory, the implants are inserted and the axillary incision is closed in two layers, including the deep dermis and skin wound. I prefer to approximate the skin incision with 5-0 nylon sutures. A similar dressing to that described earlier is placed.

Following the procedure, patients are generally managed with a period of abstinence from heavy exercise of approximately 6 weeks. They are started on a program of implant displacement exercises (Fig. 3-23A-C) on postoperative day 1 or 2 when a smooth-walled implant is used according to their comfort level. The purpose of this
treatment is to maximize the mobility of the implant and the distensibility of the periprosthetic capsule. I personally believe that this maneuver helps keep the implant as soft as possible, and it may limit the occurrence or extent of capsular contracture. This opinion is shared by many plastic surgeons.²⁹,³⁰ More important, this maneuver is something that the patient can do to help her recovery and preserve the softness and natural feel of her result.

In addition to the displacement exercise regimen, we emphasize the importance of clinical breast examinations³¹ (CBEs) to all patients. More important than this is long-term physician follow-up examinations. I offer patients yearly follow-up visits for the rest of their lives at no charge to them. I do this so that I can be satisfied that they are being examined by a physician who is experienced in the examination of the breast that has undergone an augmentation. Most important, we recommend postoperative mammograms on the schedule as prescribed by the American Cancer Society.³² Mammography remains the most accurate way of making the diagnosis of breast cancer. In breast augmentation patient, special views that involve displacing the implant are routinely employed.³³ When this technique is employed, implant-related complications are rare.³⁴ Although there is a decreased sensitivity of mammograms following breast augmentation,²⁶,³⁵ there is no evidence that the diagnosis of breast cancer is made at a later stage in patients in patients who have undergone breast augmentation when compared with patients who have not undergone breast augmentation.³⁴, ³⁵ and ³⁶

See Table 3-1.

As previously noted, revision of a previous breast augmentation is not an uncommon operation.⁷,¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶ and ¹⁷ When patients present for such surgery, they are almost always a number of years removed from their previous procedure(s). In this setting, the surgeon must be very clear about exactly what is bothering the patient. Again, this understanding comes from a very careful history of not only the previous surgery(ies), but also any changes that have occurred since the time of her last operation. A good deal of time must be spent with each patient seeking a revision of a previous breast augmentation to understand her particular problem and to formulate the best possible treatment plan. The surgeon must communicate with the patient, emphasizing realistic goals, limitations, and potential
complications. This will build the best possible doctor-patient relationship that I find so helpful during the recovery from additional surgery—especially if there are additional complications.

I always ask the patient if she was happy after the original operation. Her response often not only gives me insight into her specific complaints or concerns about the augmentation procedure, but also reflects the patient’s general sense of satisfaction and can be an indication of whether she can be content with the results of additional surgery. Comments such as “they were never large enough,” or “they were always so hard,” or “they never felt natural” can be very telling, especially if the physical inspection of the breast and the examination is at variance with these comments. Occasionally the patient will make an unsolicited comment about her previous surgeon or surgeons, and this too may provide some insight as to whether I will be able to achieve an improvement in her situation with which she will be happy.

The patient’s chief complaint should be as focused as possible. Is the patient bothered by the size, lack of superior fullness, or any asymmetry (i.e., of the shape, contour, IM fold level or definition of the fold, or position of the implants)? It is important to understand the patient’s feelings about her nipple position, the degree of firmness of the implant, and the relationship of the breast parenchyma to the implant. Is there evidence of significant capsular contracture? Are there problems with implant edge palpability, obvious folds that show through the skin, or implant malposition? When such malpositions (e.g., lateral, superior, inferior, or medial displacement of the implant) exist, they may be increased in certain postures or positions. If there are
particular positions that bother the patient, specific descriptions of these circumstances should be elucidated. Is there pain or discomfort in the breast(s)? The etiology of such breast pain or mastodynia in the setting of a previous breast augmentation is often difficult to establish and most of the time is multifactorial. I most often tell the patient that there is no surgical solution or surgical cure for breast pain. Has there been a change in the appearance of the breast, and if so what is the time course of the change? Is there a history of previous implant rupture or deflation of a breast implant, and if so how was that problem treated?

As I have suggested, it is important to have a complete understanding of all of the patient’s previous breast procedures. This includes the chronology of and time interval between the operations, as well as implant types, sizes, and position of placement. It is important to inquire about whether any of the procedures were associated with acute complications, and if so how these complications were managed. Any history of trauma to the breast(s) must be noted. Not uncommonly the surgeon will elicit a history of a closed capsulotomy that was done after a silicone gel breast augmentation. In the past many patients routinely would undergo such a manipulation if early firmness of the implant was detected following breast augmentation.³⁷ This practice has been documented to be associated with an increased incidence of breast implant rupture.³⁸,³⁹ Such treatment of mechanically squeezing the previously augmented breast is now discouraged and it should no longer be done.

A systematic examination of the breasts is then carried out as described in Chapter 2. The surgeon should note the general appearance of the breasts, scanning them for symmetry in terms of contour, fullness, nipple areola position, and position of the breast relative to the chest wall structures. Any obvious asymmetries are immediately noted. Next, more subtle asymmetries are examined. The relationship of the patient’s native breast tissue to the implant must be noted. Has there been any settling of the breast tissue away from the implant?

I find it helpful to measure dimensions of the breast, including base width, height, and the extent of upper pole fullness when the breast is gently compressed against the chest wall. I then carefully measure the distance of the nipple from the fixed point of the SSN on each side, followed by measurements of the distance from the nipple to the IM fold in the midmeridian of the breast, and also the distance from the inferior aspect of the NAC to the IM fold. I then record all of these measurements on a breast diagram in the patient’s chart (see Fig. 3-2). I find that it is very helpful to refer to this initial diagram of the breast whenever I perform any breast surgical procedure. This diagram is especially helpful when planning a revisional procedure.

A simple and useful way to think about complications following breast augmentation is to divide them into those that are related to the surgical procedure itself, and those that are related to the implant or to the biologic integration of the implant by the body. Surgical complications that are noted within the first 4 weeks following surgery are referred to as acute complications. These include hematomas, seromas, infections, and problems with wound healing, including wound separation with implant exposure. A rare complication is that of superficial venous thrombosis in the superficial veins on the inferior breast, known as Mondor’s disease. More commonly seen is a thrombosis of the small superficial veins in the axillary region in patients who undergo breast augmentation using a transaxillary approach (Fig. 3-24).

Complications seen within the next 2 months are termed as subacute complications, and these mainly refer to implant malposition. Most often this consists mainly of excessive fullness in the upper pole of the breast that is noted in the early postoperative period. This is not uncommon when the implant has been placed in the subpectoral position. In my experience this is the most
commonly noted abnormality early on after breast augmentation. From my perspective, in these situations there is little concern that the implant will descend to the appropriate level if the implant was noted to be in the appropriate position at the completion of the operation. Most often the implant will settle into a lower position as the pectoralis major muscle stretches out during the first 4 months following surgery. However, if significant malposition of the implant in a medial, lateral, or inferior location is present at 3 months following surgery, it can lead to a permanent breast asymmetry or deformities that very well might represent an indication for revisional surgery on the breast(s) later in the postoperative course. Additional surgical or technique-related complications are decreased nipple sensibility; breast asymmetry; implant edge palpability; and the presence of ripples, ridges, or folds that can be seen through the skin. The latter three conditions are noted if the dimensions of pocket dissection is inappropriate—either too large or too small.

Late complications following breast augmentation are seen much more frequently. Most of these are implant related. These would most notably include implant palpability,¹⁸ ridges or rippling at the edges of the implant,⁴⁰ implant malposition either inferior or superior in location and that result in either inadequate or excessive superior pole fullness respectively, lateral implant subluxation, medial implant malposition, or symmastia if medial implant malposition is bilateral. Implant malposition is noted with increased frequency due to the use of increasingly larger saline implants. Contour deformities may occur long after the placement of the implant and these can be related to capsular contracture.⁹

Inherent risks of breast implant placement are the result of the patient’s biologic incorporation of the implant or problems related to this process. The most commonly occurring of these is capsular contracture.⁸, ⁹ and ¹⁰ Also seen are dynamic deformities of the implant related to contraction of the pectoralis muscles in patients who have undergone retropectoral positioning of their implants (Fig. 3-25), which is a difficult problem to address. Finally, implant failure marked by rupture⁴¹, ⁴², ⁴³, ⁴⁴ and ⁴⁵ with gel extrusion if silicone gel has been used, or deflation if a saline implant has been employed,¹⁴, ¹⁵, ¹⁶ and ¹⁷,⁴⁶ is commonly seen following a previous breast augmentation.