Patterns of skin excision

• Wise pattern, also known as a ‘keyhole’ due to its shape.
  
  
  
  • Alternatively known as an ‘inverted T’ due to the resultant scars.
  
  
• Regnault described a ‘B’-shaped skin excision.
  
• Lejour popularised vertical skin excision.
  
• Marchac described vertical excision with short lateral extensions.
  
• Benelli popularised the periareolar technique.

Design of the pedicle

• Blood reaches the NAC via a pedicle from the chest wall, composed of:
  
  
  
  • Glandular tissue, or
    
  • Glandular tissue and de-epithelialised dermis, or
    
  • Horizontal septum of Würinger.

Implant shell

Implant content

• Liquid silicone gel
  
• Cohesive silicone gel
  
• Saline
  
• Hydrogel
  
• Triglyceride
  
• Hyaluronic acid
  
• Only implants filled with silicone (semi-liquid or cohesive) or saline are available in the United Kingdom.

Shape

• Round
  
• Anatomically shaped
  
  
  
  • Designed to resemble the natural breast contour.
    
  • Less upper pole projection; more lower pole projection.
    
  • Anatomical implants have various projections, heights and widths.
    
    
    
    • This allows selection of an implant for a specific breast shape.
    
    
  • Particularly suitable for thin patients at risk of excessive upper pole fullness.
  
  
• There is controversy about whether shaped or round implants produce a better result:
  
  
  
  • Proponents of anatomical implants claim they produce better breast shape.
    
  • Proponents of round implants argue that:
    
    
    
    • Round implants become anatomically shaped when held upright.
      
    • Anatomical implants may rotate within their pocket.

Incisions for insertion

Site of implant placement

Findings of the IRG in the United Kingdom

• An Independent Review Group (IRG) was set up in the United Kingdom to examine evidence for claims that silicone had adverse health effects.
  
• In 1998, the report concluded silicone breast implants are not associated with greater health risk compared to other surgical implants.
  
• There was no evidence of:
  
  
  
  • Association with abnormal immune response.
    
  • Association with typical or atypical connective tissue diseases or syndromes.
    
  • Increased risk of connective tissue disease in children of implanted women.
  
  
• Silicone implants are associated with a number of local complications:
  
  
  
  • Implant rupture
    
  • Capsule formation.
  
  
• The report recommended a national implant registry to record details of all women undergoing breast augmentation.

Findings of IMNAS in the United States

• In the United States, the Institute of Medicine of the National Academy of Science (IMNAS) released its final report in June 1999, concluding:
  
  
  
  • No evidence that silicone implants are responsible for any major diseases.
    
  • Women are exposed to silicone constantly in their daily lives.
    
  • No evidence that recurrent breast cancer is more prevalent in women with implants.
    
  • Silicone breast augmentation is not a contraindication to breastfeeding.
    
    
    
    • Cows’ milk and infant formulas contain higher levels of silicone than breast milk from women with silicone implants.

Lymphoma

• In 2008, Dutch researchers studied a group of women with a rare lymphoma.
  
• A case–control study found women with breast implants had a higher association with a rare anaplastic large T-cell lymphoma (ALCL) subtype than those without implants.
  
  
  
  • The odds ratio for ALCL associated with breast prostheses was 18.2.
  
  
• Nevertheless, only 34 cases of ALCL have been reported in women with breast implants throughout the world.
  
• This is a fraction of the estimated 10 million women who have received breast implants worldwide, making the absolute risk of ALCL very low.

Aetiology

• Cause of capsular contracture is unknown; suggested factors:
  
  
  
  • Biofilm on the implant shell.
    
    
    
    • Biofilm: ‘a complex aggregation of microorganisms growing on a solid substrate’.
      
    • S. epidermidis was found in 90% of capsules removed for contracture, compared to 12% of capsules removed for other reasons.
      
      
      
      • Implants may be washed in antibiotics or povidone–iodine for this reason.
    
    
  • Implant location.
    
    
    
    • Submuscular placement is said to be associated with less contracture.
    
    
  • Implant size.
    
    
    
    • Implants >350 cc have greater incidence of contracture.
    
    
  • Surface covering of the implant.
    
    
    
    • Polyurethane foam covered implants have less reported contracture.
      
    • The Allergan Core study showed textured and smooth silicone implants have similar contracture rates.
      
      
      
      • However, most textured implants were used in reconstruction patients, who were expected to have a higher capsular contracture rate than observed.
    
    
  • Haematoma.
    
  • Silicone gel bleed, causing local tissue irritation.
    
  • Foreign body reaction.
    
  • Genetic predisposition.

Classification of capsular contracture

• Baker classified capsular contracture:
  
  
  
  • Grade I: the augmented breast feels as soft as an unoperated one.
    
  • Grade II: minimal—implant palpable, but not visible.
    
  • Grade III: moderate—implant easily palpable, and it (or distortion from it) is visible.
    
  • Grade IV: severe—the breast is hard, tender, painful and cold. Distortion is often marked.

Incidence

• Data from the Core studies show Baker III/IV contracture rates of:
  
  
  
  • Allergan Natrelle^® implants (10 years): 18.9% for primary surgery; 28.7% for revision surgery.
    
  • Mentor MemoryGel^® (8 years): 10.9% for primary surgery; 24.1% for revision surgery.

Treatment

• Patients with Baker grade III or IV contracture often seek revision surgery.
  
• Options include:
  
  
  
  1. Closed capsulotomy
     
     
     
     • Squeezing the augmented breast until it ‘pops’, indicating capsule rupture.
       
     • Not recommended due to high recurrence rate, displacement or haematoma.
     
     
  2. Open capsulotomy or capsulectomy
     
     
     
     • Capsulectomy associated with lower risk of recurrence, but more complications.
       
     • Capsulectomy decreases breast volume, which may not be desirable.

• Capsulectomy may be preferred over capsulotomy in these circumstances:
  
  
  
  • If the capsule is very thickened or calcified, causing contour irregularity.
    
  • If the implant has ruptured, particularly if it is a Poly Implant Prothèse (PIP) implant.
  
  
• Scott Spear advocates capsulectomy, either partial or total, with replacement of the implant in a dual plane.

Recommendations of the UK Department of Health Expert Group

• Providers of PIP implants should offer consultation and investigation to determine whether implants are intact.
  
• Patients whose providers are unwilling to do this should be referred to a specialist via their general practitioner (GP).
  
• If there is any sign of rupture, explantation should be offered.
  
• If the implants are intact, discussion with the patient should include:
  
  
  
  • Risks of surgery for revision augmentation—greater than for primary augmentation.
    
  • If the implants are not removed, there is ongoing risk of rupture.
  
  
• If the patient decides against early explantation, annual review is offered.

Joint surgical guidelines for PIP implants

• Authored by five UK surgical organisations, including the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and British Association of Aesthetic Plastic Surgeons (BAAPS).
  
• Surgeons should remove or exchange implants using conventional techniques, through the original incision where possible.
  
• Biopsy and capsulectomy is recommended for extensive capsular thickening, inflammation or contracture.
  
• Biopsy or capsulectomy is not required for uncomplicated, soft capsules without evidence of silicone impregnation or local inflammation.
  
• When there is extreme silicone contamination, consider deferring implant replacement.
  
• Patients with extensive lymphadenopathy or parenchymal lumpiness should be investigated and discussed by a breast multi-disciplinary team (MDT).
  
  
  
  • Patients should be informed of the additional risks of any planned axillary surgery.

Early

• Infection, bleeding, seroma (1–3%)
  
  
  
  • Deep infection often requires explantation.
  
  
• Decreased nipple sensation (15%)
  
  
  
  • Nipples can also become hypersensitive and painful—may take months to improve.

Late

• Problematic capsular contracture
  
• Rupture rate
  
  
  
  • The Allergan Core study showed a rupture rate of 13% for subjects and 7.7% for implants at 10 years (primary augmentation, revision augmentation and reconstruction).
    
    
    
    • Up to 35% of ruptures are asymptomatic.
    
    
  • The Mentor Core study showed a rupture rate of 13.6% at 8 years (primary augmentation).
    
  • The Danish MRI study showed a 15% rupture rate at 10 years.
  
  
• Problematic scarring (5%)
  
• Visible creasing and folding of the implant.

Lipofilling

• Most suitable in these circumstances:
  
  
  
  • For augmentation by one cup size.
    
  • For increased upper pole fullness.
    
  • Following ‘conservative’ breast cancer surgery.
  
  
• Advantages:
  
  
  
  • Relatively easy to learn.
    
  • Less scarring than implant augmentation or flap reconstruction.
  
  
• Disadvantages:
  
  
  
  • Fat necrosis, oil cysts and microcalcification, which is visible on mammograms.
    
    
    
    • These changes can be differentiated from cancer by experienced radiologists.
  
  
• Effects of stem cells on breast tissue are controversial.
  
  
  
  • Long-term follow-up studies have not shown increased rates of local recurrence of cancer, but these case series are relatively small.
  
  
• Recently, technical refinements have been described that achieve significantly larger breast augmentation, more fat graft placement and higher graft survival rates.
  
• This involves using the Brava^® device, a bra-like vacuum-based external tissue expander, that is said to enlarge the subcutaneous and periglandular tissue matrix.
  
  
  
  • Brava may also increase the vascularity of the breast.
  
  
• After 4 weeks of expansion, lipofilling is done into this expanded, vascular breast.
  
• Disadvantages include wearing the Brava, which many cannot tolerate for prolonged periods of time.
  
• Lipofilling in this procedure requires 10–14 needle puncture sites per breast, which carries a risk of hypertrophic or keloid scarring in certain patients.

Hyaluronic acid

• Non-animal stabilised hyaluronic acid (NASHA), also known as Macrolane™, was previously authorised for breast augmentation.
  
• It is now known that Macrolane in the breast can make diagnosing breast cancer more difficult, particularly with mammography.
  
• The manufacturer (Q-Med) has since discontinued this indication for its product.