Breast augmentation surgery: Clinical considerations

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Figure 1
Silicone breast implants. Left, textured and anatomically shaped; right, smooth and round. Note the sloping projection of the anatomic implant. The fuller portion would be oriented inferiorly in the patient to simulate a native breast shape.
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Figure 2
Placement of breast implants.
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Figure 3
The images in the top row are before breast augmentation. Those in the bottom row are 7 months after breast augmentation surgery with 350-cc smooth, round silicone breast implants placed via an inframammary incision in a subpectoral pocket.

TABLE 1

Silicone breast implants by generation

First generation (1960s)
Shell	Thick, smooth, silicone elastomer in 2 pieces with Dacron patches posteriorly to facilitate positioning along the chest wall
Filler	Silicone gel, moderate viscosity
Shape	Anatomic or “teardrop”
Complications	High capsular contracture rate (approached 100% at 10 years after implantation)
Second generation (1970s)^a
Shell	Thinner, smooth, seamless, no Dacron patches
Filler	Silicone gel, thinner and less viscous
Shape	Round
Complications	Rupture (nearly 60%), diffusion or “bleeding” of silicone molecules into periprosthetic space and onto breast implant capsule
Third generation (1980s)^b
Shell	Thicker, multilayer silicone elastomer, no Dacron patches
Filler	Silicone gel with larger particles, increased crosslinking, more viscous and thick
Fourth and fifth generation (1990s to present)^c
Shell and filler	Shell thickness and gel viscosity redesigned according to strict criteria by American Society for Testing Methodology and US Food and Drug Administration
Shape	Anatomic (teardrop)

↵a During this period subpectoral implant placement gained popularity, decreasing capsular contracture rates.
↵b Restricted from US market temporarily in 1992; textured surfaces were introduced during this period in an effort to decrease capsular contracture.
↵c Greater quality control during manufacturing; wider variety of implant shapes and surface texturing available.

TABLE 2

Advantages and disadvantages of silicone and saline breast implants

	Advantages	Disadvantages
Silicone	Consistency with palpation mimics dense, natural breast tissue Quicker adjustment to alterations in the external environment	Exposure to silicone in the event of rupture, and rupture not immediately evident Higher initial cost (nearly double that of saline implants), including cost of recommended monitoring (imaging) to ensure implant integrity
Saline	Only a small incision is required for implant insertion (implant filled with saline to desired volume through a port) Saline is safely absorbed by the body in the event of rupture, and rupture is immediately evident (breast deflation) No concern for silicone exposure in the event of rupture	Overfilling leads to increased firmness, palpability of the implant edge Underfilling results in rippling and a higher risk of rupture from the shell folding upon itself Consistency with palpation mimics water (as opposed to natural breast tissue) Slow to adjust to alterations in the external environment (eg, feels cold after swimming) Slightly higher rate of rupture

TABLE 3

Considerations in incision location

Location	Advantages	Disadvantages
Inframammary	Most common choice Excellent visualization of both the subpectoral and suprapectoral planes of dissection	Visible scar along inferior pole of the breast
Periareolar	Excellent exposure of the implant pocket Less sensory deficit to lower breast pole	Potentially higher rate of capsular contracture Associated with moderate-severe implant malposition and increased risk for secondary procedures Greater propensity for nipple-areola complex dysesthesia Scar located on visible breast surface
Transaxillary	Ideal for saline implants (only require small incisions) Does not affect subsequent sentinel lymph node biopsies High satisfaction rate vs inframmary incisions	Difficult route to place silicone implants Associated with moderate to severe implant malposition and increased risk for secondary procedures
Transumbilical	Remote incision, may be obscured by umbilicus	Less control of implant positioning