Team Approach to Education

The first step in the process of breast augmentation is the educational component; this step is the most critical aspect of the process and is frequently neglected by plastic surgeons. This approach solidifies a surgeon/patient partnership before surgical intervention, because this process requires not only the surgeon but also the entire staff of the clinical practice to be an integral participant in the subprocess of patient education. Thus, the surgical team has a responsibility to introduce the patient to the philosophy of the surgical practice. Instructional material and promotional multimedia may serve as an adjunct to the standards of the practice and influence patient education.

The patient and practice must create a partnership for implant selection and postoperative care. Together, they develop a mutual understanding that the implant will not only be selected based on patient preference, but also must incorporate breast dimensions and tissue characteristics. The patient must understand the limitations of her breast envelope and the implications of implant selection based on breast topography. Together, they will review patient images and physical attributes to delineate breast asymmetry and anatomic boundaries that impact implant selection. Furthermore, the practice patient educator and surgeon have a responsibility to discuss various implant options (eg, silicone vs saline, anatomic vs round, textured vs smooth) and how the selected implant is influenced by patient characteristics. This partnership in implant selection and postoperative care has been proven to enhance patient satisfaction and overall esthetic outcomes. Recently, in our practice, 3-dimensional imaging has significantly revolutionized this partnership by allowing patients to visualize how an implant “fits their breasts,” as well as potential differences between shaped and round implants.

The informed consent process is integrated into the educational process ; the risks should be discussed including, but not limited to, bleeding, infection, capsular contracture, implant malposition, rippling, and need for reoperation. A preoperative understanding of the complication profile will empower the patient to assume responsibility for the final decision. A new development that deserves attention during the patient consultation is the association of anaplastic large cell lymphoma (ALCL) and breast augmentation. Current evidence suggests the risk of developing ALCL is 0.1% to 0.3% per 100,000; in relative terms, a patient is approximately 2 times more likely to be struck by an asteroid than to develop ALCL. Patients typically present with a delayed seroma after 1 year. The clinical course is indolent, and effective treatment includes removal of the implant and capsulectomy. Adjuvant therapy is rarely recommended. Fewer than 50 cases have been reported in the medical literature, but patients should be aware of this recent finding. Initial studies have suggested a correlation of ALCL with textured implants and/or certain bacteria, but more investigations need to be undertaken for any definitive conclusions.

Determine Patient Knowledge/Patient Desires

The process of patient education and informed consent requires a multimodality approach. More often than not, patients have a misconstrued perception of breast augmentation based on previous experiences or multimedia influence. The surgeon and practice have a responsibility to dismantle any misconceived notions and educate patients on the relationship of breast tissue and implant selection. Our practice requires each patient to complete documents before an education consultation by our patient education specialist ( Fig. 1 ). This consultation, in person or over the phone, typically lasts 45 to 60 minutes and discusses concepts, issues, and limitations related to the process of breast augmentation. This consultation is able to decontaminate any misinformation and convey the importance of tissue-based planning and implant selection. For example, the coordinator can dispel the inaccurate association of cup size and breast augmentation; most women wear inappropriate bras for their cup size and cup size is nonstandardized within the industry. At this time, the patient educator also can determine if the patient desires a “natural-look” or an “augmented-look” for her breast augmentation; this mentality will directly impact the rest of the consultation and implant selection. Again, 3-dimensional imaging can be an integral component of this discussion; patients can project various “looks” and can even overlay a bra or camisole on these simulations to optimize visualization. Thus, patients and surgeons can select the implant based on the breast envelope and implant characteristics rather than improper misconceptions.

Our breast augmentation patient educator consultation checklist.

The education coordinator initially performs the consultation with the patient, typically done in person or on the phone, as a separate consult that precedes the surgeon consultation. During the surgeon consultation, the surgeon can objectively review the breast dimensions, confirm the patient’s goals, and formulate a surgical plan. In the patient-surgeon interaction, asymmetries are identified and directly addressed using an image analysis sheet ( Fig. 2 ). Patients must have realistic expectations on intermammary distance, cleavage, implant characteristics, and implant palpability. By dispelling any misconceived notions, the surgeon and the patient can synergistically select the appropriate implant based on individualized tissue. Additionally, with joint preoperative planning and implant selection, patients will accept their postoperative results and rarely present for size-exchange procedures. Approximately 20% of patients in our practice may question their size postoperatively, but they are reminded of the preoperative planning with the associated photographs, which usually reaffirms implant size selection and patient satisfaction.

Our breast augmentation patient image analysis checklist.

Shaped Versus Round

Breast implants can be either round or anatomically shaped. Of note, round implants are used in 95% of primary breast augmentations in the United States. Within both subsets, there are a wide variety of widths, heights, and projections. Anatomic implants may even have more variability because of their naturally asymmetric shape. Plastic surgeons should vary implant selection to optimally “best fit” a breast envelope. However, surgeons may use only one implant style because of their training or comfort. Our practice believes some situations dictate a certain implant based on patient preference or breast anatomy. Superseding all of these sentiments is the concept that the best patient for an anatomic implant is the patient who “wants it.” Indications for both round implants and anatomic implants are outlined as follows:

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  Round implants

  
  
• 1.
  

  Desired augmented look

  
  
• 2.
  

  Good soft tissue coverage/good basic breast shape

  
  
• 3.
  

  Revision surgery (change of implants, capsular contraction, implant rupture, rotation)

  
  
• 4.
  

  Recurrent implant rotation/concerned about rotation

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  Anatomic implants

  
  
• 1.
  

  Desiring a natural look with minimal or no breast tissue

  
  
• 2.
  

  Shapeless breast or breast with poor soft tissue coverage

  
  
• 3.
  

  Constricted lower pole or tuberous breast deformity

  
  
• 4.
  

  Simple or complex asymmetry

  
  
• 5.
  

  Ptosis or lower pole laxity (poor tissue may limit placement)

Smooth Versus Textured

Textured devices were initially created to mimic the external shell of polyurethane implants; these implants had a coarse porous exterior with very low capsular contracture rates. Recent Level 1 trials have not demonstrated lower capsular contracture rates in textured implants in the subpectoral pocket; however, some clinical studies have suggested reduced capsular contracture rates using textured implants in the subglandular space. Most likely, the low capsular contracture rates seen in polyurethane implants were related to a biochemical reaction and not the texturing of the device. Of note, smooth implants are currently used in approximately 90% of patients receiving primary breast augmentation in the United States. Our practice uses texturing only for anatomic implants.

Saline Versus Silicone

A patient’s anatomy or personal preference may dictate saline or silicone filler; however, the fillers have distinct properties that should be discussed during the initial patient consultation. Advantages of saline implants include smaller incisions from a remote location, less required monitoring, and decreased costs. Disadvantages of saline implants include increased risk of wrinkling and palpability, less natural touch, more tissue effects over time, and spontaneous deflation. Advantages of silicone implants include less wrinkling and palpability, no risk of sudden deflation, and a more natural touch. Disadvantages of silicone implants include MRI monitoring, “silent rupture,” increased costs, and a slightly longer incision. The implant choice in our practice is typically selected by patient preferences and breast anatomy.

Pocket Plane

Implants can be placed in the subpectoral, subglandular, subfascial, or dual-plane pocket. Advantages of the subpectoral position include improved upper pole contour, decreased incidence of capsular contracture, and better breast tissue visualization during mammography. Disadvantages include increased discomfort from submuscular dissection and potential rare occurrence of implant distortion by pectoralis contraction, although a proper dual-plane pocket negates all these disadvantages.

Subglandular placement of implants may be appealing because of misconceptions of decreased postoperative pain and ease of dissection; however, the disadvantages of subglandular positioning typically outweigh these positives, including poor superior pole esthetics and rippling, increased capsular contracture, and difficult mammography imaging.

Subfascial placement has been suggested by various investigators to offer the same protection as submuscular placement against capsular contracture with less postoperative pain; however, the pectoralis fascia layer is typically thin and requires a tedious dissection. Our practice has found minimal clinical indications for subfascial placement.

The dual-plane technique places the implant partially subglandular and submuscularly. Incremental and planned release of the submuscular fibers at the muscle-gland interface allows the surgeon to vary the muscle coverage of the implant leading to optimal implant–breast parenchyma dynamics. Dual-plane position eliminates virtually all of the disadvantages of the traditional submuscular approach while maintaining the benefits of muscle coverage. All implants placed in our practice are dual-plane with the exception of true body builders.

Incision Selection

Popular available incisions for breast augmentations include inframammary, peri-areolar, axillary, and peri-umbilical. Certain patient anatomy or implant choice may suggest an incisional approach; however, often the chosen incision is patient/surgeon preference. The inframammary approach continues to be the most popular access for breast augmentation, as it provides the best control. This approach offers visualization of the subpectoral plane without violating the breast parenchyma. Indications for this incision include small areolar diameter, large form-stabled implants, glandular ptosis, and large-volume implants (>400 mL). The real challenge/key point of the inframammary approach is placement of the incision at the postoperative inframammary crease (the new inframammary fold [IMF] incision). If the placement is miscalculated and the inframammary crease is repositioned intraoperatively, the scar will not be in the optimal location and poor quality. Furthermore, a malpositioned IMF would alter the postoperative nipple-to-IMF distance and inherently distort overall breast esthetics. The inframammary approach has evolved as the preferred surgical access of our practice; this incision is predictable and reproducible when implant-specific tissue-based principles are followed and provides the most control. We place the calculated postoperative fold starting 1 cm medial to the areola, then extending a length laterally that will accommodate the size of the implant (typically 4–5 cm).

The peri-areolar incision hemi-circumnavigates the areola, usually hidden with an inconspicuous scar at the pigment of the areola and native breast skin; however, recent studies have shown an increase in bacterial load, and subsequently, increased capsular contracture with this incision. Thus, we typically avoid this access choice in our practice.

Axillary access for breast augmentation is an intriguing approach because many surgeons market this access as scarless. Indications for axillary breast augmentation include small areola diameter and small silicone implants or saline implants. The patient also must have appropriate breast anatomy: adequate breast tissue, normal body habitus, and ideal shape. This incisional approach can be either blunt dissection or endoscopic assisted. Of note, blunt dissection is technically easier but requires experience, and the endoscopic approach necessitates complex technical equipment. Both axillary techniques have an increased risk of superior implant malposition because of the poor visualization of the inframammary crease. Furthermore, this procedure may be more painful, and revisional surgery normally requires an additional remote incision. Surgeons must avoid the axillary fat during this dissection to prevent lymphatic trauma and associated sequelae. Some science has demonstrated a higher capsular contracture rate with the trans-axillary incision as well, although some proponents of the incision have documented similar rates.

The peri-umbilical approach (trans-umbilical breast augmentation) has been discussed in the literature for saline devices. This approach requires an extensive blunt dissection in the subscarpal plane to access the subpectoral pocket and is typically reserved only for surgeon preference. The approach has many drawbacks and does not execute breast augmentation at the highest level.

During the education and surgeon consult, patients who desire various incisions are presented these data points, and in the past 5 years, all have requested the new IMF incision.

Limitations Patients Should Understand

There are certain patient anatomic variations that may influence implant selection and deserve mentioning. For example, plastic surgeons and patients must recognize chest wall morphologies, which can affect the orientation of the breasts, and thus, the positioning of the implants. A round chest wall lateralizes the breasts; and alternatively, a rectangular chest wall medializes the breasts. Patients are counseled that the position and morphology of the breast on the chest wall cannot be altered with breast augmentation. Furthermore, hemithorax asymmetry or scoliosis may require different implants despite equivalent breast volumes to recreate symmetric chest topographies.

A separate unique patient population is the postpartum breast augmentations. After pregnancy, the breast tissue atrophies with poor skin elasticity. This skin/soft tissue transformation may accentuate implant visualization and migration. Silicone implants with conservative volumes may decrease postoperative rippling and bottoming out. Furthermore, these patients may have nipple hypertrophy and nipple/breast ptosis. Concurrent nipple correction or mastopexy may augment the overall cosmesis.