Breasts have always been a sign of Femininity and the lack of breast volume is a major cause of concern for girls and women. Also sometimes there is an imbalance between the upper and lower body and hence the breasts appear smaller than they actually are.
Breast Augmentation or enlargement is a surgical procedure done to improve the contour, projection and volume of the breast.
Done for cases where there is absence of breast since birth or when the breast size is small or after childbirth when the breast loses its volume, the result being a feeling of inadequacy.
Many women fight breast cancer and chemotherapy - but feel incomplete after the struggle, as they have lost a part of their femininity. Breast reconstruction using implants or flaps helps these women regain a piece of their femininity. This part is dealt with in Breast Reconstruction.
""Women coming in for breast enhancement surgery have to take an active role in deciding the size, the shape of the breasts and how much cleavage they want to have.""
In fact, patient input is very important. The possibilities are varied and the procedure has to be catered to an individual’s needs and likings. So, the patient needs to be explicit and clear about her desires and explain the same to the surgeon.
The patient's desires and physical realities many a times don’t match up and this is where the surgeon’s role comes into play, in helping the patient decide and setting realistic goals. This is done after examination of the present shape and size of breast, elasticity of the skin of the breast, position of the nipple and shape and contour of the patient's chest wall, etc.
Unequal breasts are a cause for concern with many women. But rest assured it is perfectly normal. About 95% of normal woman have unequal breasts. But the augmentation can give us a chance to correct this by using two different sized implants in case the discrepancy is too significant.
No two women are alike and so there is no one implant or operation that will suit all women. The procedure has to be decided on an individual basis.
Breast augmentation in most commonly performed using silicone implants which are discussed below. Recently there has been a trend towards using the patient’s own fat to augment the breast called ""Autologous Fat Transfer to the Breast"". This is discussed later on in the page.
Implants come not only in many sizes but also many shapes, from round to tear drop or anatomic, low or high profile. The shape a woman wishes to achieve is measured against her existing breasts and her chest wall to determine the appropriate shape and size of the implant. Implants are commonly filled with silicone gel.
The silicone gel implants are permanent (?) as they do no deflate. But they require a larger incision size. They have a natural feel and the new highly cohesive gel implants do not leak even if they are punctured or cut.
The saline implants are silicone bags into which saline is injected to fill it up. The advantage of these implants is that smaller incisions to place the implant are required and the sizes can be increased or decreased in case of volumetric discrepancies between the right and the left breasts. But, the disadvantage is that the saline may leak over a period of many years and the implant may have to be replaced. But these are no longer available
Apart from the type of implant with respect to the content there are also different sizes and shapes and textures of implants. All these choices are discussed with the patient during the consultation and then a decision is taken. The choice of the implant is usually left to the patient.
Incisions can currently be placed in one of three places for implant introduction. Incision choice is dependent on the implant type and size chosen, and the comfort level and experience of the physician with that particular incision.
Inframammary (crease) incision: . The incision is placed just in the skin crease where the breast meets the chest wall usually along the breast meredian. It allows easy placement of the implants. This approach is useful if bigger sized implants are to be inserted. But the problem is that there is a visible scar on the lower part of the breast which usually settles with time but doesn’t vanish. The scar usually merges with the skin crease over a period of time. This is the most commonly used approach to breast augmentation the world over.
Transaxillary incision: The incision is placed in the armpit. The benefit of this incision is that it is in a natural crease, there is no chance for increased stretching of the scar since there is no weight or tension against the incision after implant placement. But since the incision is far away from the site of actual placement of the implant the size of the implant that can be inserted is limited. Secondly, the dissection is more extensive and hence the pain is a little more. Thirdly, the scar maybe visible when wearing sleeveless dresses and lifting the arms. In some cases the the nipple sensation recovery also takes longer. But, the most important drawback of this incision is the fact that if the implant has to be changed or any corrections need to be done then they cannot be done through the same incision and the cut has to be converted to the one below the breast.
Periareolar incision: The periareolar incision is made at the border of the areola and the skin and will hopefully be hidden there. However, the skin may stretch during the healing process and the scar may widen slightly. The size of the implant which can be inserted will also be limited by the size of the areola, if this approach is chosen. There is a chance for decreased nipple sensation for a few months. Some of the ducts may be damaged during this approach but usually don’t cause any problem during breast feeding.
Trans Umbilical or TUBA: Here the incision is placed inside the umbilicus or belly button and hence is hidden. Only saline implants can be inserted by this method. It is also called the ""Scarless Breast Augmentation""
Plane of placement of Implant:
SubFascial: This is a newer approach popularized by Dr.Ruth Graf from Brazil. Here the implant is placed under the covering or (fascia) over the pectoralis major muscle. This gives all the advantages of a sub muscular placement without the pain of a muscle dissection. Sometimes though this layer is not well formed and in those cases we do a sub muscular placement. This is our preferred area of placement since the last 4-5 years.
SubMuscular or SubPectoral: Placement of the breast implant under (behind) the pectoralis muscle is preferred in women with anatomically less breast tissue since the results are more aesthetic. The pectoralis muscle covers about two thirds of the upper part of the implant. This placement allows for less chances of rippling, though it may still occur in areas not covered by the muscle - specifically the outer sides and bottoms of the breasts. Advantage is that, the normal breast tissue is far away from the implant and hence does not interfere with self breast examination and mammography at a later date. Muscle contractions may flatten the implant out a little. Placement behind the muscle does not preclude exercise of those muscles and one can get back to regular activities in a few weeks time. Also, the incidence of capsular contracture is decreased with this placement. This is the most common area of placement of implants.
Sub Glandular or Pre Pectoral: Placement of the implant over the pectoralis muscle provides a more distinct cleavage line than placement under (behind) the muscle. It also allows for larger implant placement. The recovery time is shorter and pain associated is less with placement over the muscle. The implant shifts less when compared to placement behind the muscle. Patients who are body builders or too muscular or sportswoman tend to go with this placement. But capsular contractures are more and if breast tissue is thin, then the ripples of the implant and edge of the implant may be seen on the skin.
Though every attempt is made to give the best possible result, because the body healing varies, some problems may occur as with any other procedure.
The scar in the inframammary or periareolar approach may be visible.
Sometimes, the volume of the breast may vary on the left and the right side which will depend on the amount of breast tissue already present there.
Sometimes when the implant is placed behind the muscle, it stays high and the normal breast tissue if less or lax tends to slide down giving a double bubble appearance on standing. More commonly seen in the axillary approach. Over a period of time the implants “settle down” coming to a lower level than where they were initially, as the swelling abates and this problem settles, but rarely some minor adjustments may be required.
Rarely bleeding is a problem but adequate care is taken during the procedure so prevent such complications. In case there is a collection of blood and if quantity is small it may be left alone as it usually gets absorbed but, if the quantity is more then it may require evacuation of the collected blood.
If there is excessive sagging of the breasts, breast tightening or reshaping “ Mastopexy”, is combined simultaneously along with the breast enlargement.
The most common fear or myth related to use of implants is the risk of cancer. All studies done till date have shown no proof as to the association of breast implants with an increased risk of Breast cancer.
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Autologous Fat Transfer to the Breast or Scarless Breast Enlargement :
Though structural fat grafting has been done for many years now in other areas of the body like the buttocks and the face very commonly, it was not being advocated in the breast for fear of the calcifications caused by some of the dead fat in the breast interfering with mammograms thereby hampering cancer detection protocols.
But, now studies have proved conclusively that the calcification patterns of these fat cells and the calcification patterns of cancers are totally different and can be distinguished. Hence there is a renewed interest in fat grafting to the breast to increase breast volume.
The fat is harvested from other areas of the body and then concentrated and injected into the breast in different planes to augment the size of the breast. So, it is basically a combination of liposuction of one area and lipo filling of the breast.
The only disadvantages of this procedure are the facts that the patient must have fat in other areas from where to harvest. Secondly, the take of the grafted fat i.e the amount of fat that ultimately stays on in the breast is a little unpredictable and many a times a second procedure is required after 6-8 months to refill the breast to the desired volume.
But as the techniques are getting better & with our better understanding of the survival processes of the grafted fat, the results will get better To improve graft survival we now routinely use PRP (platelet rich plasma) along with our fat grafts.
Stem cell Breast Augmentation:
Breast Augmentaiton with Stem Cells is being tried out and in combination with autologous fat transfers. Initial results look promising but we still await long term results. Fat is harvested via liposuction and some of it is sent for mesenchymal stem cell isolation and culture. After three weeks of culture the stem cells are injected into the breast tissue.
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