Breast Implantation
Breast Implantation
In the case of aesthetic breast augmentation, also known as augmentation mammaplasty, an implant, i.e. alloplastic material is inserted in order to increase the size and to enhance the shape of the breast.
This is one of the most frequent aesthetic plastic surgery procedures. According to estimations at present more than two million women have breast implantation in the world.
The History of Breast Implantation
The first aesthetic breast implantation was carried out by Czerny in 1895, when he implanted a lipoma removed from the patient's back to replace the adenoma which he removed from the breast. In 1945 Berson experienced with the free transplantation of own fat but the indeterminablle absorption made his results worse.
The Silicone
After oxygen the element silicon occurs in the second greatest quantity in the earth's crust, in our environment. It is the basic constituent of eg. minerals, sand, quartz (both being silicon-dioxid), the silicates, glass, cement etc.
Silicone is polydimethyl-siloxane, i.e. a chain polymer (macro-molecule) containing siloxane (-Si-O-Si-) bonds.
The Application of Silicone Implants
The first life-saving silicone implants were those shunts (1950) that were used in the case of hydrocephalic children in order to shunt the intracranialis liquid. Later the silicone became the basic constituent of many products which are used in the field of medicine eg. the constituent of the tracheotomic tube, of eye pieces, of artificial heart valves, the covering of hypodermal needles or the reconstructive implants used in tumour-surgery or in cases of developmental abnormality. Since 1960s more than 2.000 scientific studies have dealt with the safeness and effectiveness of the silicone, in the context of both animal and clinical experimentation.
The assumption that silicone may cause autoimmune diseases appeared first in Japanese medical writings in 1964. The article was about several women into whose breasts liquid (not gel) silicone was inserted previously, mixed with another kind of oil or paraffin.
This assumption was disproved by different scientific analyses, but patients appeared with newer and different complaints. The most frequent problems have been well-known for a long time, they are mentioned in this chapter in the section that deals with the various complications.
In 1989 the FDA still declared that it was not reasonable to assume that silicone implants were unsafe. However, a lot of articles appeared in the newspapers arising fear in the patients, enumerating „health damages" with high-sounding titles such as „toxic breasts" or „time-bombs in the breasts" etc. The hysteria grew high, especially when the FDA's moratory came into effect.
In 1992 FDA (Food and Drug Administration) proclaimed a moratory which banned the commerce and application of the silicone gel breast implants. However, its usage was allowed for women who underwent mastectomia, who were in need of this implant and participated in the long-term scientific studies.
The FDA acknowledges the safeness of the silicone and permits testicle- and penisimplants, birth-control devices with silicone content, and liquid silicone as eyesurgical substance to be used for the replacement of the retina, and makes these attainable in the future, too. The FDA also allows the use of silicone in food, cosmetics and medicines.
How can the silicone enter the body?
There are two ways:
- • 1. From the gel stock of the breast implant. The rate of deflation is 1-
- • 2. The other possibility is that of rupture. According to the FDA this phenomenon could be experienced in 4.6% of the cases. Generally the silicone stayed within the capsule, thus the rupture remained mute. If the silicone reaches the blood-circulation, it does not migrate any further, because it is hydrophobic, i.e. it resists water and water solutions as well as tissue fluids such as water and lymph. However, in some cases it was also detected in lymphatic glands after the insertion in the breast as well as in other orthopaedic implants.
Most manifestations against implants are anecdote-like and appear mainly in the media as a sensation, having little scientific basis. Fundamentally there is a natural reaction in people to sum up facts in a way that if a thing is followed by another, then this latter becomes inevitably the consequence of the former. They believe this to be true in the case of implants as well. Connective tissue disorders have frequently been detected already before the implantation, not to speak of the fact that their unknown origin is well-known.
Several countries have not accepted the American (partial) moratory, moreover in Europe the EQUAM ( European Committee on Quality Assurance and Medical Devices in Plastic Surgery) issued its own report. We are quoting the latest view in effect, dating July 4, 1998.
The Indications of Breast Implantation
- • I. Glandular hypomastia: which can be of developmental or involutional origin.
- • I.A. As a result of developmental abnormality the skin, the subcutaneous tissue and the
gland stock are of non adequate size.
- • I.B. Involutional if it is only the volume of the gland stock that becomes smaller, generally after birth giving and nursing. In this case there is a relative overweight of the skin and the subcutis, usually we meet cases of ptosis or pseudoptosis. In the cases of second and third degree ptoses (i.e. the nipple is 1-3cm or so below the submammar furrow) dermal mastopexy is necessary. Aesthetic breast augmentation corrects developmental abnormalities or first-degree cases of involutional origin with an adequate size.
- • II. The asymmetry of the breasts (except ptosis of second-third degree): In some cases of developmental abnormality enlargment with a tissue-expander may also come into consideration as the first step.
- • III. Cases of mastectomy resulting from breast tumour: In our country breast cancer occurs in 33 out of 100.000 inhabitants. Every year 30.000 new tumour cases are diagnosed. In the 20th century it is essential for women to possess information about the possibilities of breast reconstruction surgery procedures since it is unfortunately becoming a more and more frequent disease throughout the world.
- • IV. Psychic factors may also be the cause of surgical procedures, when the patients’ breast that are judged as inadequate, which may cause inferiority complexes, depression and sexual complexes. Psychiatric analyses proved that in these cases the surgical procedure performed led to the growth of self-confidence, higyer self-esteem and satisfaction had a positive effect on the patients' private life.
In general we can say that 96% of the patients are satisfied with the outcoming result, 97% of them would undergo the surgical procedure once again, only 1% woul not, and 70% receive positive response also form their environment. 42% of the patients have a better sexual life, 60% do sports regularly, 69% change their lifestyle to a healthier one after the surgical procedure.
Choosing the Size of the Implant
Since the size of the implant is determined by its volume, diameter and height, the most ideal implant has to be chosen through taking these factors into consideration, besides the patient's demands.
When the patient requests big and round breasts, it is advisable to choose high profile implants. When the patient demands a less remarkable change in size and wants a so-called 'more natural shape', then rather low profile or drop-shaped implants come in question. Most women are able to formulate their wishes only according to the size of their bra. In most cases the cupsize of the bra becomes 1-2 sizes larger (from 75A to 75B or
It is interesting that the application of smaller implants oftens result in relatively larger growth in size in cases of larger breast and chest volume. It is advisable to choose the appropriate implant by placing a sample of the suggested form and size into the patient's bra during the examination.
The patient's individual features, like the volume of the breast tissue, features of the skin, diameter of the chest, height of the patient, width of their hip are all factors which have to be taken into consideration.
The existence and degree of ptosis, which is the disproportion between the skin and the volume of the gland, also make the selection of the appropriate implant more difficult.
When the ptosis is of third, large degree (the nipple is
In cases of minimal or moderate ptosis (the nipple is on the level with the inframammar furrow or just below it, but it is not positioned downward) the shape can be corrected with augmentation but the choice of a bigger implant has to be considered in order to fill in the sagging skin.
One thing is important to know. In cases of developmental abnormality tissues are less capable of dilatation, thus a larger size can be achieved only with two surgical procedures.
The Surgical Incisions of Breast Implantation
The surgical incisions of breast implantation
A: submammar
B: axillar
C: periareolar
Before the surgical procedure the contours of the area to be prepared, the patient in a sitting and lying position. The incision is normally 2-4-
The incision can be:
- • A. submammar
- • B. axillar
- • C. peri-and transareolar
- • D. other (eg. transumbilicar, mamma- or abdominoplasty)
The Surgical Procedure in Details
The importance of asepsis and antisepsis cannot be sufficiently emphasized in case an extraneoous subtance is inserted into the body. The patient's appropiate isolation, covering the skin with OpSite, the usage of 2 pairs of gloves, the complete cleaning of the gloves from the talcum are all advisable measures.
The surgical procedure is generally recommended to be performed with general anaesthesia. However, the application of epinephrine local anaesthesia may be advantageous as well, since it decreases bleeding during the surgical procedure, and thus it is easier to undermine (0-5 % lidocaine solution can be used with the addition of 1:200.000 epinephrine).
After the incision and the atraumatic undermining careful haemostasis is essential.
The pocket should generally be larger than the implant itself, since thus the implant can easier be inserted and its tightening can be avoided.
The edges of the undermining are usually the medial edges of the sternum lateralis, the frontal axillar line on the side, and the size appropriate to the diameter of the implant at the top and at the bottom. The middle of the implant should come under the nipple.
It is practical to undermine bluntly, thus damages of the internal medialis strands of the artery mammaria and the strands of the veins and nerves of the lateral intercostalis can be more easily avoided.
If the implant is placed under the pectoralis maior muscle, the layer has to be created above, between the pectoralis maior and minor. The inferomedialis origin of the pectorlais maior has to be bluntly disjoined so that the muscle cannot move the implant up- and outwards.
The wound should be washed out with diluted 5% betadine solution thus removing the blood and the possible tissue fragments. There are surgeons who change gloves to insert the implant, but it is better if the surgeon is the only one who touches the implant.
The process of insertion has to be performed with great care to avoid damaging the implant due to some rough technique. In general we can say that the implant is most likely to be damaged during the surgical procedure. After the insertion it is very important to be convinced that the implant is not creased, since later this becomes more tangible.
Checking symmetry is another very important question. For this the upper end of the operating-table may be lifted. The lower edges and the interior-exterior humps of the implants and the position and direction of the nipples have to be checked. Post-operative asymmetry in most cases is due to the asymmetrical undermining of the pockets, in case the breasts had previously been symmetrical.
It is practical to use a suction drain, since the surface of the wound is big, in the first 24 hours even 130-150 ml mucus may empty out.
The wound may be closed in 2 – 3 layers. Continuous intracutaneous skin stitches should be used. After this the scar should be covered with Steri-strip, then with a covering press bandage.
Post-operative Treatment
The patient may receive preventive antibiotics before the surgical procedure (eg. it is practical to give 1g mandokef) then a per os wide spectrum medication in the first post-operative days, to which the different Staphylococcus and Streptococcus phyla are susceptible.
The patient has to be asked to avoid all physical activity, to leave her dressing untouched and to wash her bust with the help of a sponge. The patient should take her temperature every day. In case the patient has any complaints it is recommended to see her doctor immediately.
The first check-up is either during the removal of the drain (that is on the first post-operative day) or on the 3rd-5th day. The dressing is removed, ther Steri-stripes are changed, the scar is checked.
In case of subglandular insertion it is advisable to wear the bra continuously for 2 weeks. If the implant is later judged as being a little lower than the ideal level, the patient is to be asked to wear the bra continuously for another 6-8 weeks. If the implant is higher an elastic band or a flexible gauze placed along the upper edge of the wound would help to achieve the more ideal position. (Except in the case of PU-covered implants, which stay at the very place where they were inserted.) A flexible fixation of 6-8 weeks can also be recommended in cases of axillaris and submuscularis implants.
It is useful to take out the continuous sutures 2 weeks later. The patient can take showers 3-6 days later. It is advisable to resume physical activities only a month later. It is useful to supervise the patient monthly for half a year, then a year after the surgical procedure, then yearly.
Complications
Haematoma
According to surgical statistics its rate of occurence is 2-3%. It can be easily detected, since soon after the surgical procedure it causes the painful swelling of the breasts, which the feel stiff when touched and in some cases a blueish discolouring may also be detected.
Its treatment is surgical. The wound has to be opened with general anaesthesia, the accumulated blood has to be emptied out, haemostasis has to be applied. If it is not treated, the haematoma damages the blood circulation of the skin, the healing of the wound, it may increase the infection of the wound and the possibility of capsular contraction and assymetry. If haematoma is of small degree and detected duriing the firsz check-up due to moderate assymmetry, It can be treated conservatively.
The occurence rate of seromas can go up even to 10%, especially in the case of structured implants. Seromas of a smaller degree can be expected to be absorbed spontaneously, but the suction of larger degree seromas may be reasonable.
The rate of infection may usually be 1-4%. In general we can say, that the breast parenchyma is in constant connection with the skin of the nipple through the ducti. In most cases positive aerobe and anaerobe bacteria cultures can be extracted from the breast tissue, and even from the undermined pocket. The most frequently grown bacterium is the aerobe Staphylococcus epidermidis, but anaerobe bacteria, even fungi and myobacteria occur.
The classical symptoms – swelling, the feeling of discomfort, secretion, the possible appearance of the implant in the scar, high temperature and fever – appear mainly 10 days after the surgical procedure, but may also occur at any time. Immediate treatment is essential. It is necessary to clear the secretion, open, drain and frequently wash the wound with some antibacterial solution, and to give the patient a systematic antibiotic treatment.
With the full knowledge of bacteria, specific treatment can be performed. The implant does not always have to be removed, especially when inserted with periareolar incision, but severe capsular contraction may be expected. The most frequently grown pathogenes are the Staphylococcus aureus and epidermis. In case the implant is removed, the new implant can be inserted 2-3 months after the symptoms have disappeared. Implants can be used only once. As in the case of haematoma, prevention is of utmost importance here as well. The same duties are recommended which have been enumerated in the section dealing with the surgical procedure.
The hypertrophial scar is rare in periareolar incision, but it may occur in the case of submammar incision.
Nerve damages at the nipple-areola have an occurence rate of 15%. It is mostly due to an over-agressive, sharp undermining which may damage the intercostal nerves. In the case of submuscular insertion the possibility of mobilizing the nerves is of a higher degree, thus the medial periareolar and submuscular insertions may be more advantageous from this point-of-view. The considerate, dull underminig is very important, especially on the lateral side.
Risk factors specific to implants
The most fundamental problem of mammaplasty is capsular contraction.
In case of each patient in whose bodies alloplastic material is inserted a capsule, i.e. a scar tissue develops around the extraneous material. The contraction of the capsule presses the breast implant into the shape of a ball, thus the material loses its flexibility. The stiffness of the breast, which goes with its painful, hard and tight condition and possiblly visible distortion, is called spheric fibrotic capsular contraction (SFCC). It occurs almost in 40% of all augmentation mammaplasty cases, in various degrees.
SFCC depends on:
- • the type of the implant (salt-water solution or silicone gel-filled)
- • the surface of the implant (plain, textural , PU-covered)
- • the positioning of the implant (subglandular, submuscular)
- • medicaments used during the surgical procedure (steroids, antibiotics)
- • post-operative treatment (expansionary exercises)
In the case of salt-water solution-filled and textural implants the rate of contraction is smaller, in the case of PU-covered implants it is 1-2%, and it is smaller in the case of subpectoral than in subglandular insertion.
There are two theories concerning the development of capsular contraction: the infectional and the noninfectional:
- • A. The noninfectional theory
According to the noninfectional theory it is the silicone itself that causes SFCC. It is well-known that the wall of the implant, the elastomer is semi-permeable, thus th esilicone polymer molecules that are of appropriate size can permeate it and get into the fibrotic capsule (bleeding). More of these molecules were found around the silicone gel-filled implant than around the fillable implants. (1982) However, the thickness of the capsule is not in proportion to the severity of the clinical symptoms. The number of myofibroblasts that can be found in the capsule is larger in the contractioned shell. These cells can be found everywhere in the active phase of normal scar-healing, but they disappear in older scars.
According to the hypertrophial scar theory the development of capsular contraction is due to the nyofibroblast activity. (This phenomenon has no connection with the hypertrophial scar formation of the skin.) The experimentations with early steroid treatment was due to this theory. Triamcinolon was placed in the wound cavity which gathered at the bottom of the wound and this caused the submammar tissues growing thin. With its injection into the implant the effect of methylprednisolon as determined by the size of the dose proved to be favourable. 20 mg of methylprednisolon significantly decreased the rate of SFCC without causing the breast tissue growing thin and without throwing out the implant. In spite of this, according to the present view it is not recommended to fill the implant with medicaments that have a lasting effect.
The introduction of expansionary exercises, i.e. moving the implant in all directions so that the capsule can remain as large as possible, decreased SFCC significantlly, from 58% to 28% (1977). Histological examinations proved capsule formation right on the third post-operative day, thus this form of treatment is reasonable only in the first post-operative period. Too drastic massages are not recommended because of the risk of possible bleeding.
According to some authors, E-vitamine dosing may be useful, especially during the first week.
- • B:The infectional theory
The other theory is the infectional according to which SFCC is caused by subclinical infection. The basis of this theory is that the Staphylococcus epidermis can be grown from the milk-ducts of every breast. (1979)
In 80% of all cases the same can be detected in the sublandular breast capsule (1985). The use of antibacterial medicaments to which the Staphylococcus epidermis is susceptible decreased the ooccurrence rate of SFCC with 90%. Double blind experiments proved that the 5% betadine solution and the cephalotin plus-salt solution have similar effects.
The clinical symptoms of SFCC can be classified into 4 degrees according to Baker (1978):
- • I. degree: there is no tangible or visible capsule, the touch of the breast is the same as that of an unoperated breast (Symptomless state.)
- • II. degree: minimally tangible stiffness of the breasts, but their appearance is normal
- • III. degree: moderate stiffness of the breasts, the implants are easily tangible with the visible distortions of the breast contours
- • IV. degree: severe stiffness of the breasts, distortion that is well visible, the breasts are stiff, painful and cold
The possible treatments of capsular contraction:
- • First there were attempts at closed capsulotomy. The surgeon pressed the patient's breasts until the typical audible bursting indicated that the implant has broken. At present producer companies do not recommend this form of intervention because of the possible rupture of the implant and the possibility that the silicone gel migrates into the soft parts.
- • Open capsulotomy is a surgical procedure. It means incision and expansion along the edge of the capsule in a circular and radier direction.
- • By capsulectomy the partial or complete removal of the capsule is meant.
When capsulotomy was combined with the replacement of the plain-surfaced implant, the possibility of recrudescence was of 37-39%, except when the implant was replaced with a different type. With the application of PU-covered implants the rate of SFCC recrudescence could be decreased (1988) to 4.2% when combined with anterior capsulectomy, while to 29.3% when the new implant was re-inserted into the intact fibrous capsule.
The most effective treatment to prevent the development of a new SFCC has been the insertion of a new implant into the pocket, which can be combined with the removal of the capsule; nevertheless it is important that the implant should be inserted into a newly undermined cavity.
The occurrence rate of asymmetry is 12%. It is due to differences between the created pockets and capsule formation.
The implant creasing occurs in appr. 7.8% of all cases. In these cases the creases at the edge of the implants are tangible and visible. In order to prevent this it is important to create pockets of appropriate size and to place the implants evenly.
When throwing out the implant, it may appear on the scar or through the normal skin. It is most frequently caused by inflection or by the erosion resulting from implant creasing, the application of steroids or by wearing too tight bras.
The split between the breasts may disappear when the cavities of the two sides meet.
The rupture or break of the implant happens due to a trauma, for example even during the surgical procedure.
Part of these cases remain 'mute' and are discovered only during another operation; mammographic, ultrasound, MRI or CT examinations may help their detection. In these cases the replacement of the implant is necessary.
The Mondor disease means the thrombophlebitis of the inframammaris veins. (1983) The string like veins are mainly tangible when the patient's arms are raised, on the chest wall under the line of the scar. It does not necessitate treatment as with time it disappears spontaneously.
Pneumothorax is a rare complication which can develop during the infiltration of local anaesthesia or the injection of the intercostalis blocade.
Conclusion
Most women are not discouraged by the possible complications mentioned above. Scientific studies so far have proved that in spite of the rumours the chance for tumour in the case of operated women is 30% less than in the case of those who do not have implants. There is no scientific explanation for this, maybe these people pay more attention to themselves or they lead a healthier lifystyle. At the same time, patients with implants appear on th eprescribed routine check-ups, and examine their breasts more freyuently and thus are usually treated sooner and with smaller tumours, and as a result, their breast tumour mortality is 30% less than those women's who do not hane implants.
The most important is to explain the patient that self-examination is of utmost importance in the early detection and effective treatment of tumour cases.
If the intervention is performed with appropriate expertise and care, the number of problematic cases may be significantly reduced.
Concerning the surgeon's responsible activity we have to repeatedly emphasize that he who performs breast implantation has to bring his expertise to the best possible and most up-to-date level.
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