Breast surgery can be accomplished using any one of four incision sites

1. Nipple areolar
2. Axillary armpit
3. Inframammary under the breast
4. Umbilical belly button

Four types or shapes of implants in both saline and silicone are available

1. Smooth
2. Textured
3. Round in shape
4. High profile teardrop or anatomical shape

Three sites of placement are routinely used

1. Above the muscle
2. Below the muscle
3. Below the fascia

There are many options 4 x 4 x 3 48 total and many other less common variations plus the range of implant volumes possible

Silicone implants are still available in special circumstances and in most all other countries around the world

You and your surgeon should have the same goal of achieving the most beautiful and natural result possible And the surgeon will explain why some of these alternatives may be better for you than others

The following information may help you understand the differences in the approaches described above

Site of incision

Allowing the patient to choose the site of the incision may sound like an upsetting idea to some surgeons but more than 98 of the patients will accept the doctors recommendation anyway so why not allow the patient to have as much say in the matter as possible

For the patient whose breasts droop enough so that the skin of the breast is touching the skin of the chest wall when standing erect the inframammary incision placed slightly up on the breast just 1 2 to 1 cm above the new inframammary fold should be almost completely hidden and may be the preferable and most recommended sight

In the patient with very small areolae the areola incision may be nearly impossible It is preferable to have this incision at least 2 cm long and if it is to be less than 1 5 cm and the patient really insists on not having it under the arm we may insist on permission to extend it laterally as much as 1 2 to 1 cm in each direction because it may not be possible to get an implant of over 200 cc volume through it

Ordinarily we tell our patients the following 1 The areola incision made in the wrinkles of the brown skin of the areola heals with the least scar 2 The inframammary incision is most visible of all except in pendulous breasts and 3 The axillary incision is the least visible of all unless the patient is a ballet dancer or for some other reason has her arms in the air with the axillae exposed very frequently

The techniques of the different approaches and associated problems will be discussed in detail in further chapters The patient may wish to know that the areola approach is the only one of the three that invades the breast tissue yet in performing this in hundreds of women and knowing others who have also done hundreds with this approach I have yet to see or hear of breast nodules or cysts developing in the lower portion of the breast because of this approach Many patients I have done with this approach have subsequently become pregnant and were able to breastfeed

Also with the areola approach there has been no greater incidence of hypaesthesia numbness of the nipple or lower breast skin than with the other approaches in my experience of performing more than 500 surgeries using areola incisions

There is an article in the literature that states that patients who have the areolar approach have more difficulty breastfeeding than those with the axillary or inframammary incisions This is a retrospective study and is unreliable but the suggestion may still be correct

Type of Implant

Almost always the patient will accept the doctors recommendation for the type of implant There were seven implant manufacturers before 1992 and the FDA Now there are only four McGhan Mentor PIP and Hutchinson And their names addresses and phone numbers are listed in their web sites The choice of implants for the surgeon is discussed in chapter twelve of our handbook on breast implant surgery

At times these companies will have videotapes on how to do the surgery Wells Johnson supplies endoscopic equipment for the umbilical approach and has videotapes of that approach

What the patient wants is the best possible result with no future problems Many of the reasons for choosing a saline over a gel or a combination or the meme is because of the rationale each one has for reducing the chance of or preventing the capsule contracture problem The meme was the best But since it was covered with polyurethane foam it was removed from the market and will probably never return It was this interface of texturing that led to the textured silicone implants

Historically in the beginning after it was discovered that silicone injections could lead to unacceptable complications and silicone was first placed in a silicone bag the first implants in the early 1960s were silicone gel They were firm and teardrop shaped The capsule contracture rate was greater than 90 with most being as hard as your elbow except for whatever breast tissue was overlying them So softer implants were developed in the late 1960s

These softer implants would assume a teardrop position in the upright position and so the teardrop shape was no longer necessary Dacron patches were popular at that time to hold the implants up and while they did this to a certain extent the capsule contracture rate again approached 100 because of tissue reactions to the Dacron As well the breast tissue continued to sag over the implants even when the implants stayed firmly fixed to the chest wall this resulted in distortion Dacron patches are very rarely used now

In the early 1970s saline filled implants were introduced and were softer than a gel implant in the same patient when independent observers compared one side to the other The problem with the saline implants is the leakage and deflation rate which seems to be about 50 over a period of 10 years in my experience with about 100 pure saline and around 500 combination gel and saline implant surgeries Yet many of the pure saline and many of the combination implants that I used 20 to 25 years ago are still intact

Implant deflation necessitates an additional operation and since there is no doubt that some capsule contraction occurs with saline implants why do we have the additional problem of deflation For example I removed some saline implants that had been put in previously and had already required one revision because of deflation one side was completely collapsed and the other had a capsule The implants were small and the patient could have tolerated the firm side but was chagrined to have the asymmetry of a complete collapse of the other so we replaced them both with silicone gel implants The gels formed more and harder capsules but were more popular than saline implants because of the reduced deflation problem not because the result was more natural or softer The saline implants were in fact softer than the gels

When considering gel bleed as a cause of capsule contraction please note that many patients have a capsule develop only on one side and usually the capsule firmness and thickness is unequal on the two sides Not only are a few capsules unilateral but most patients have unequal firmness and often it is markedly unequal with a soft breast on one side and spherical contracture and deformity on the other These well known findings must be considered for any theory of capsule contracture Gel bleed would occur almost equally and could not cause such asymmetry in capsule formation

The choices as of the year 2000 are all saline textured or smooth and to be filled with a valve or prefilled

We see and have seen rippling from textured silicone as well as saline implants But the saline implants ripple to a greater extent and are more palpable ie they can be felt and detected by feel more easily

Textured implants have thicker walls and can ripple more The McGhan 468 or anatomical implant is textured but still can ripple It feels more firm and is more palpable below the nipple where the tissues are thin The 468 is a shaped overfilled fairly firm implant but it does not allow much of a stuck on appearance Because it is overfilled and less mobile it does not seem quite as natural as the softer smooth salines But in selected patients it can be the best implant made

The smooth implants have less rippling than many of the textured and are less palpable and less firm than the McGhan 468 But they could be subject to more capsule contracture

So the FDA presumption or suspicion was that the silicone gel is more likely to cause autoimmune disease or cancer than solid silicone Yet these reactions on the immune level are microscopic and the difference in the gel and the solid silicone chemically on the level of the molecular structure is analogous to the difference in ice and water And if the chemistry is the same the molecular reaction is approximately the same

Saline implants are the only type approved by FDA as of the year 2001 and there is a thorough discussion of the reasons for this There is a history of implants and a presentation of McGhan and Mentor the only manufacturers now approved for implants

Other factors for the choice of implants will be discussed further elsewhere Even if gel were to return many probably would continue to use saline because they are good implants they may cause less capsule contracture they require smaller incisions and they have an overall reputation of greater safety from all the unproven but suspected problems associated with gel

FDA Panel Deems 2 of 3 Breast Implant Brands Safe

By Lisa Richwine

GAITHERSBURG Reuters The two most popular brands of saline filled breast implants are safe and effective and should stay on the US market a federal advisory panel said Thursday after reviewing new data on possible complications

The committee said however that the company that makes a third brand of saline implants did not present enough information to prove the benefits of its product outweighed its risks

Saline implants first hit the market more than 25 years ago when the FDA had no authority to determine whether they were safe The agency is scrutinizing them now because of concerns about complications such as infections and rupturing

The FDA usually follows its panels advice and is expected to decide whether to officially approve the implants later this year

Breast implants are more popular than ever About 150000 women received them last year Most are filled with saline or salt water Silicone gel implants were banned for most women in 1992 over safety concerns

The panel recommended the FDA approve implants made by Inamed Incs McGhan Medical unit and Mentor Corp two California companies that lead the breast implant market

The data shows these implants are reasonably safe and effective said panel member Dr Phyllis Chang of The University of Iowa College of Medicine after studying McGhans results

But panelists said they were not reassured by data from Poly Implant Prostheses PIP They said the US study the company presented did not include enough patients that were followed for an adequate time to truly evaluate the device risks

Panel member Boyd Burkhardt a plastic surgeon from Arizona said he wanted to support PIPs implants because he thought their design would dramatically reduce the rate of infections But he found the companys data incomplete and found it difficult to understand that the company was as ill prepared as you appear to be

PIP President Rick Hawk responded by saying the study results showed there was reasonable assurance of PIPs implant safety and effectiveness

Earlier McGhan said a one year study of more than 2500 women showed the most common problem was contraction of scar tissue around the implants which can cause changes in breast appearance and deflation That occurred in 7 2 percent of women who had breast augmentation and in 12 5 percent of women who had breast reconstruction

Leakage or deflation happened to 3 6 percent of women who had augmentation and 2 6 percent of reconstruction patients

An FDA official who analyzed the companys studies said the risk of complications increased over time Dr Sahar Dawisha said 95 percent of reconstruction patients had reported some type of complication after five years

Studies on serious ailments such as connective tissue or autoimmune diseases were not designed well enough to draw any conclusions about whether they were related to the implants Dawisha said

Silicone Safe

A major report finds that silicone breast implants dont lead to cancer

Women who have silicone breast implants are no more likely than the rest of the population to develop cancer immunological diseases or neurological disorders a committee of the Institute of Medicine IOM reported on June 21 Moreover mothers with implants may safely breastfeed their infants as there is no evidence of toxicity in the milk The IOM committee drew its conclusions after holding public hearings and reviewing scientific literature on silicone breast implants and silicone

The analysis is the latest in a series to have found such results

Still the IOM committee points out breast implants are not without risks The tissue around the implants may contract causing pain and disfigurement and leading to infection by skin bacteria that normally reside in the lactiferous ducts of a healthy breast Also implants have a finite life span and rupture rates of gel implants and the deflation frequencies of current saline models have not been determined Problems lead to additional surgery to replace or remove them

Not everyone is convinced by the IOM report Some believe that a study based on other studies called a metaanalysis is inherently flawed because of assumptions made about the quality of previous research In any case implant manufacturers have already agreed to a total settlement estimated at 4 billion with plaintiffs who claimed physical harm now bankrupt Dow Corning will be paying the most some 3 2 billion

Christina Reed

Subglandular Subpectoral or Subfascial

Originally when augmentations were first performed in the early 1960s with silicone breast implants they were placed in the subglandular position over the pectoral muscle

They were hard or became hard They were hard to begin with If you look at the old Dow Corning product descriptions of the implants there were no soft implants in the early sixties They were teardrop shaped often with Dacron patches on the back and they all became hard and were quite firm before they were implanted

Since the early type implants were firm to begin with they were expected to be firm and capsule contracture was not felt to be a major problem

This may be one of the secrets of the polyurethane coated Meme implant That is that they are firm to begin with and therefore do not contract into a ball so easily like the softer implants do In those early days firmness was thought to be desirable to a certain extent anyway

Then in a few years in the late sixties the patients were asking if something couldnt be done about the hardness and softer implants were soon on the market Then in 1967 CO Griffiths first reported the submuscular implants in augmentation

As the capsular contracture problem became more common with the softer implants more surgeons shifted to the submuscular technique until now there are and have been many articles and opinions in the literature that the implants tend to remain softer in the submuscular position The advantages of the subpectoral position are

1. Dissection is just as easy as prepectoral position
2. Bleeding is no greater
3. Hemostasis is as easily obtained
4. It is substantiated in the literature
5. It is about as popular as prepectoral if not more
6. The muscle over the implant reduces the feel of hardness if contractures occur
7. The muscle movement presses on the implants and may thus keep them a little softer
8. The muscle over the implants provides a smoother straighter contour from clavicle to nipple without a demarcation line no stuck on look
9. The muscle force pushes the implants down counteracting the tendency of the capsule contracture to push the implants superiorly
10. The implants are further removed from breast tissue with less chance of being involved in breast diseases lactation or breast biopsy
11. There may be less numbness of the nipples due to less damage to the third fourth and fifth intercostal nerves
12. It is said to be better for mammography to have implants placed below the muscle

The main disadvantages of submuscular implants are

1. Anesthesia especially local is more difficult to achieve
2. Postoperative pain maybe greater
3. The muscle may be weakened
4. The muscle force may push the implant down too far
5. There appears to be less cleavage but this is debatable
6. Patients may have a flatter appearance with less projection of the breasts forward
7. The muscles may be visible over the implants when contracted and press the implants laterally
8. The breasts may not feel as soft or move as freely
9. If capsule contracture occurs closed capsulotomy is more difficult

With all these different debatable considerations one can see that there is no definite best way for all patients Each patients special circumstances may determine which implant position is best for her

For example if the patient is very slender with very little subcutaneous or breast tissue covering the upper chest the patient is a good candidate for submuscular implants

If however the patient has considerable subcutaneous and breast tissue to cover the implant and is particularly desirous of cleavage the submammary position might be better For the patient who is a professional or serious amateur athlete who uses her arms often such as with bowling golf tennis swimming etc thorough counseling is needed to choose the best approach

A newer approach has now emerged since 1996 and that is the subfascial approach

The subfascial placement of breast implants has many of the advantages of submuscular position without lifting the muscle attachments from the ribs The subfascial placement has become the preferred position for the placement of breast implants in our practice The clinical experiences with more than 1000 breast augmentations in the subfascial position are reported The indications for this technique are proposed The incidence of complications are described from clinical experience and compared to other methods The longest term of after surgery observation has been more than three years The average time of observation of these cases has been about eighteen months We have used the subfascial position through axillary areola and inframammary incisions As implants are placed routinely below the muscle through the umbilical approach it can be done through that incision as well

The subfascial position prevents the stuck on appearance caused by the interruption of the clavicle to nipple line just as the submuscular does It is a little less potent in this because it is not as thick as the muscle

The subfascial position prevents rippling above the areola just as the submuscular position does and probably as well

The SF subfascial position does not push the implant down as the muscle does in the submuscular position SM This pressure of the muscle provides some hemostasis right after surgery This force of the muscle also massages the breast implant and may help keep it soft It also prevents the rising up and too early healing of the inferior breast pocket at the inframammary fold by the muscle pressure pushing down the implant against the area of the fold It may help prevent capsule contracture by pressing the implant down All these factors are logical and reasonable and clinically seem to be correct but are unproven and may or may not be important

The subfascial is definitely less injury to the patient than the submuscular It has less morbidity The patient is less uncomfortable Also it prevents the muscle movement that is sometimes visible after submuscular placement of implants