Breast augmentation and augmentation mammoplasty are scientific terms to explain the use of artificial implants or fat used to increase the size and change the shape of the breasts of a woman. As a primary reconstruction, augmentation breast is indicated to correct a congenital breast asymmetry. As an elective cosmetic surgery, primary augmentation changes the aesthetics (size, shape, and texture) of healthy breasts.
The typical candidate to breast augmentation is a young woman with a psychological distress due to her body appearance and her body image. Patient surveys about the post-operative quality of life of women receiving breast augmentation, reported improved physical health, physical appearance, social life, self-confidence and self-esteem. Candidates for breast augmentation surgery share certain important characteristics. They need to have appropriate skin elasticity so the skin can conform to its new, improved contours. It is mandatory for patients to have realistic expectations; they should understand not only what surgery can accomplish, but also the limitations of the procedures.
For augmentation breast currently there are several types of breast prostheses coming from all over the world. There are two main types of breast implants used by plastic surgeons according to its composition: saline implants (silicone shell filled with sterile saline solution) and silicone implants (silicone shell filled with viscous silicone gel).
According to the surface of the implants there can be smooth, nanotextured, microtextured and rough textured (biocell) implants. The texture should increase the positional stability of implants and decrease formation of the surrounding fibrous capsule.
The shape of the prosthesis can be round or anatomical. Round implants have a round base and symmetric projection of the shell. Anatomical implants can have round or elliptic base and half- drop projection of the shell – a flatter upper pole and a fuller lower curve. This shape usually is associated with a youthful natural-looking female breast appearance. Another characteristics of the implant is the projection, that is the distance from the implant´s base to its most prominent point. Implant of the same volume can be of low, middle, high or extra high projection.
The surgical procedure for implantation a breast prosthesis device can be performed with four types of surgical incisions and approaches. Inframammary incision is made below the breast, in the infra-mammary fold, which affords maximal access for precise dissection and positioning of the breast implants. It is the preferred surgical technique due to its safety and comfortability. Periareolar incision is made along the breast areola, usually around the inferior half, providing an optimal approach when small breast lift is required. However silicone-gel implants can be difficult to be positioned by the use of this incision, due to the short incisional length. Transaxillary incision is made to the axilla (armpit) without producing visible scars upon the breast proper; yet is more likely to produce inferior asymmetry of the implant’s position. This approach is most prone to complications and is therefore less and less popular. Transabdominal approach combines abdominoplasty procedure and breast augmentation. In the transabdominoplasty breast augmentation the breast implants are tunneled superiorly from the abdominal incision into bluntly dissected implant pockets, whilst the patient simultaneously undergoes an abdominoplasty, so not visible scar upon breast remains.
The four most surgical approaches to emplace a breast implant to the implant pocket are described in anatomical relation to the breast gland and the pectoralis major muscle. Subglandular – the breast implant is emplaced to the retromammary space, between the mammary gland and the pectoralis major muscle. Yet, in women with thin pectoral soft-tissue, the subglandular position is more likely to show the ripples and wrinkles of the underlying implant. Subfascial – the breast implant is emplaced beneath the fascia of the pectoralis major muscle. The dual plane – the upper pole of the breast implant is emplaced beneath the pectoralis major muscle, while the lower pole of the implant is in the subglandular plane. Submuscular – the breast implant is emplaced beneath the pectoralis major muscle with release of the inferior attachment of the muscle. The submuscular implantation approach shows the best coverage of the breast implants.
Non-implant breast augmentation usually means breast enlargement using autologous fat tissue. This procedure combines liposuction, fat tissue processing and fat tissue transplantation to the breasts. The technique of autologous fat-graft injection to the breast is applied also for the correction of breast asymmetry and of breast deformities. The careful harvesting (gentle low vacuum liposuction technique) and processing (usually centrifuge) of the mature adipocyte tissue is topical. Autologous fat is then injected using blunt cannulas in small aliquots to the breast gland, pectoral muscles and subcutaneous fat. This technique allows the transplanted fat tissue to remain viable in the breast, where it provides the anatomical structure and the hemispheric contour of breasts.
The main disadvantage of the technique is the need of appropriate amount of fat tissue that is sometimes, in a very thin young female, difficult to be harvested. On the contrary, some patients can take advantage from liposuction at the same time of breast augmentation. Second reported disadvantage is the partial resorption of the grafted fat (usually from 30-50%) so this procedure must be performed several times or there is the need for primary hypercorrection. And finally it is not recommended to engraft more than 200 – 250 milliliters of fat tissue into one breast during one surgery due to the higher rates of complications. Therefore nowadays for higher volume breast augmentation several sets of surgery are required. In fat-grafting breast augmentation procedures, there is a small risk that the adipose tissue grafted to the breast can undergo necrosis, infection or calcifications.
Breast augmentation procedure using breast implants or fat tissue is always performed under general anesthesia. The operating time of breast augmentation surgery (usually 1-2 hrs) depends on the skills of the plastic surgeon, the surgical approach, the breast implant used (type and materials), type of the implant pocket, the amount of fat tissue needed for grafting. The use of fat grafts usually takes a longer period time, being on average 2 hrs.