Breast Augmentation (Breast Enlargement Procedure)
This procedure is carried out in women, who feel their breasts to be of inadequate size. It is also carried out in cases of asymmetry, where one breast is smaller than the other and in certain surgical conditions such as tuberous breast. It is also done in cases of large benign tumours (noncancerous tumours) of breast, where the removal of tumour leads to significant reduction in size of the breast.
Attainment of perky and full looking breasts is now a reality, thanks to the advances in science. For those women who desire this, the procedure of breast augmentation makes them feel more confident and complete.
Methods of Augmenting Breast
There are two main types of operations. The breast may be augmented with the help of implants or without implants. (Fat Grafting)
Breast Augmentation with Implants
There are two main types of implants, that are used today. These are-
Silicone Filled Implants: These days the majority of implants that are used, are silicone filled implants. The silicone material in these Vth generation implants is Cohesive, ie even if the implant shell ruptures due to some reason, the silicone gel stays and does not migrate to other areas, unlike the previously available implants. Silicone gel imparts a more natural feel to the breast and hence these can be placed in a subglandular location. Improvement in shell designs has also reduced the incidence of previously occurring complications such as capsular contracture.
Saline Filled Implants: These are empty shells of silicone, that are inserted through small incisions. After insertion, the shell is filled with normal saline, the same type of fluid, that can also be injected intravenously and thus is harmless. Since the consistency of saline is much thinner than silicone, these implants must be inserted much deeper, ie beneath the pectoral muscle, which lies deep to breast. If these are inserted in a superficial position, these may be noticeable to eye and touch and may cause problems such as rippling or wrinkling. However, these implants lead to an even lower incidence of capsular contracture. In case if such an implant ruptures later due to some reason, the saline that is contained is harmlessly absorbed by the body. As the implants are empty and hence, much smaller before incision, these can be inserted through smaller incisions.
The breast implants may be inserted by following approaches –
Inframammary : This is the commonest method. A 5-6 cms long incision is made in the inframammary crease (crease just below the breast), dissection done and breast implant is inserted.
Periareolar : The incision is given at junction of dark and normal skin in inferomedial part of areola and normal skin junction. This incision may be less visible than inframammary incision, expecially in light skinned ladies. This however divides a few breast ducts and may lead to some breast feeding difficulties later. Also, the incidence of capsular contracture is higher. Silicone filled implants may be difficult to insert through this incision, due to it’s smallness. This may be the approach of choice, if a breast lift is planned along with the implant.
Axillary : This incision is made through armpit. Blind dissection or endoscopic appproach with the help of a video camera can be used. This is also, the most likely to produce asymmetry of implant at it’s lowermost portion.
Umbilical : This is done through a blunt or endoscopic approach. As the incision is very small (2cms), only saline filled implants can be inserted. It also carries a risk of damage to implant shell, due to handling (passing through the small incision).
Abdominal : This approach can be used when an abdominoplasty (tummy tuck) is also being done. The implant is introduced through tummy tuck incision.
The implant can be inserted in following planes-
Subglandular : The implant is placed just deep to breast tissue. Anatomically, this is the best position for a breast implant. However, in patients with thin overlying skin and soft tissue envelope, wrinkling and ripples are likely to show through. Also, the rate of capsular contracture is higher, for this position.
Subfascial : Implant is placed deep to the outer covering of pectoral muscle, which lies just deep to breast tissue. It’s usefulness is still being debated. It may provide better coverage and stability of the implant.
Subpectoral (Dual Plane) : Here, the upper part of implant lies beneath the pectoral muscle, which is deep to the breast. The lower pole of implant, however, is covered only by the breast gland. It allows better projection of lower pole of the implant, thus better mimicking the natural condition, however, animation deformity can result (excessive movement of the implant in subpectoral plane).
Submuscular : The implant lies totally deep to the pectoral muscle.
Breast Augmentation without Implants
In this procedure, body’s own fat from areas like abdomen, buttocks, thighs, is harvested with the help of thin cannulae and suction. This fat is then processed/ refined on site by various methods such as centrifugation. This fat is then injected into three different levels (subglandular, pectoral muscle and subpectoral), depositing small quantities at each pass. External tissue expansion may be applied 10-12 hours a day, several weeks prior to this procedure, in order to create space for depositing a higher amount of fat graft. The procedure may need to be repeated a few times to achieve optimum result. This procedure may be suitable for those women, who do not want to use breast implants. The limitation is that, augmentation can be only up to one cup size in most cases.
Breast Reconstruction is the process of rebuilding breast, after it has been destroyed due to a disease such as cancer, burns, injury or removed in an attempt to get rid of tumours. The procedure may also be used for birth defects of breast.
Methods of reconstructing breast
Breast may be reconstructed using patients own tissues. This tissue, which is transferred from other areas, to produce a breast like projection is known as flap. Flaps may be harvested from muscle at back (Latissimus Dorsi Myocutaneous), Abdomen (TRAM) and Gluteal area (SGAP, IGAP). In cases where a sufficient skin and soft tissue envelope is present, breast may be reconstructed using implants, as described above. Another method, which has gained prominence recently is the use of patients own fat and stem cells, after harvesting these by liposuction and injecting these as described above, in combination with external tissue expansion.
Is reconstruction a single procedure, or other procedures are also required?
Usually, it is a two stage procedure. In the first stage, flap or implant is used to provide a projection in the breast area, which is similar to breast. In a second operation, nipple and areola is reconstructed by using local tissues and skin graft. Sometimes, more stages may be required, depending on the complexity of case. In cases of breast reconstruction with fat grafts, 3-5 sittings may be required.
This procedure is indicated for those women, who have larger than normal breasts, resulting in shoulder, neck and/or back pain. These women also may have difficulty in carrying out exercises, aerobics etc. There is often difficulty in finding proper well fitting clothes. Weight of the breasts leads to indentation of skin by shoulder straps. Intertrigo and fungal infections are common in the infra mammary crease region.
The operation is carried out to remove excessive breast tissue, followed by reshaping and contouring the breast to achieve and aesthetic result. The techniques that are used are designed so that sensation and blood supply to nipple areola complex is preserved.
During the excision and reshaping process, some lactiferous (milk) ducts are unavoidably cut. The procedure is designed to preserve most of the ducts, however some difficulty in breast feeding may occur later resulting in requirement of supplemental feeding.
BREAST LIFT (MASTOPEXY)
Over a period of time, loss of skin elasticity, variations in body weight, pregnancy and breast feeding and relentless action of gravity, take their too on breasts, leading to sagging. Sometimes, this sagging is excessive and then, surgical intervention is required for correction.
This operation is indicated for those women, whose breasts, though sagging, are of normal size and volume. If this is not the case, then augmentation together with mastopexy is required. Women with breasts that lack substance or firmness as well as those, whose nipple and areolae point downwards and especially if situated below the lower breast crease, are good candidates for this procedure.
Are there any surgical incisions/ resulting scars on breast?
Yes. One incision is circular around the areola, designed to left the nipple areola complex (NAC) to a higher, more natural position. Since this is at a natural skin junction, it remains well hidden. Another incision is vertical, proceeding from NAC to lower breast crease. The third incision is in lower breast crease and again, being at natural crease, remains well camouflaged.