As a plastic surgeon who trained in the late 1990’s and who has been in practice eighteen+ years I have witnessed many changes and evolutions in breast augmentation surgery. As I started my practice we were only afforded the use of saline implants for our cosmetic patients. These devices yielded less than satisfying results due to rippling, a very stereotypical augmented round shaped breast. The saline filled plastic bags demanded that the surgeon place the implants partially under the muscle to soften the outline and attempt to hide the rippled appearance of the implant. However, the outer edges of the breast could not be covered by the chest muscle and still showed the underlying implant. Additionally, the visual results were pleasing at first but, over time, the constant chest muscle contraction overtop of the smooth round saline implant resulted in compressing the water inferior and laterally similar to a water hammer affect. The net result over many years is an over-expanded pocket that becomes larger than the implant and, in a reclined position, the device falls off the chest wall and into the armpit resulting in widely displaced implants and breasts without cleavage. Additionally, a less than desirable appearance occurred when a woman bent forward and the weight of the implant, combined with the over-stretched skin of the upper pole resulted in significant pleating of the saline implant.
Today I do not offer saline implants to my patients because I feel the results are so inferior compared to silicone gel devices. I was trained originally in the nineties to perform mostly a blunt dissection of the muscle off the chest wall and create larger pocket sizes than the implant. The modern surgical approach utilizes finesse with meticulous dissection to create bloodless fields and to make a pocket size similar to the width and height of the device. I currently offer all types of silicone gel implants ranging from shaped to round devices with varying degrees of cohesiveness and surface textures customized to the individual needs of each patient. Looking at data collected from industry experts and reviewing my own personal results over the years I have concluded that the pectoralis major muscle, even if elevated with great precision, may introduce a number of variables overtime that reduce the long-term control of outcomes by surgeons. It is my goal to provide patients with an excellently executed surgical procedure combined with a customized implant choice leading to a desired outcome for many years, without the need for multiple revisions. Therefore, if an individual’s breast anatomy has adequate thickness in the upper pole for optimal coverage over the implant without the need for additional thickness of the muscle then I will proceed with a sub-glandular/ sub-fascial placement of the implant. If there is slightly less than adequate thickness I will recommend simultaneous autologous fat grafting to enhance the upper pole breast tissue as opposed to elevating the muscle.
Historically speaking, other indications for utilizing muscle in augmentation mammoplasty procedures was to reduce capsular contracture rates. Most experts feel that biofilm is the major mechanism leading to capsular contracture. Bacteria flora in the breast ducts can be introduced onto the surface of the implant during surgery setting up colonization leading to many antigens triggering our immune system resulting in an array of events such as capsular contracture and even implant associated lymphomas. This idea, even with a dual plane placement of an implant under partial muscle coverage, reduces the surface area of the breast directly in contact with the device. Data shows a reduction in at least one percentage point in capsular contracture in the subpectoral plane compared to sub-glandular placement. However, thanks to the contributions of surgeon- researchers such as Dr. Bill Adams, our society has good benchmark data regarding the most appropriate irrigation solutions to combat the most likely bacteria present to control biofilm as well as intraoperative techniques to minimize bacterial loads on the implant during the procedure. Utilizing all this data has led to a very low capsular contracture rate even in the sub-glandular plane of my patients, thus, I feel the risk benefit ratio still favors avoiding the muscle.
Additionally, another way to reduce capsular contracture in the sub-glandular plane is to place textured rather than smooth devices. The data is quite clear: there is a 50% reduction in capsular contracture rates with textured vs smooth devices sub-glandularly. But wait, it gets more controversial – textured implants have an increased risk of developing implant associated atypical lymphomas (ALCL). Fortunately, the number of confirmed cases is very low compared to the very large denominator of all patients who have received breast implants since the late 1960’s. In fact, the likelihood of being hit by a car while walking on the street is far greater than developing ALCL. As far as I can glean from the data, there is no stratification of ALCL of textured devised in the sub-glandular vs sub-pectoral plane. It is my belief without proof that the inflammation of textured devices under a dynamic muscle is greater than a textured device in the sub-glandular non-dynamic plane. The overwhelming majority of plastic surgeons in the United States utilize smooth implants mostly because, in the late 1990’s, textured saline implants resulted in poor outcomes with greater rippling under the muscle and higher deflation rates compared to smooth implants. However, surgeons in Europe were never forced to use saline implants and always had the availability of silicone gel devices. They have mostly embraced textured gels with excellent results and very low ALCL rates. Based on all of the risk-benefit analysis combined, I prefer a sub-glandular textured breast implant for the vast majority of my aesthetic breast patients. This device has the least capsular contracture rate with the least amount of risk for implant malposition inferiorly-laterally, and avoids a waterfall effect of the inferior pole breast tissue falling away from the implant which is held to the chest wall muscle, and avoiding any unnecessary muscle animation deformity of the breast during pectoralis muscle activation. I have also found the soft touch gels which are more cohesive than the workhorse responsive gels but less stiff than the highly cohesive gels to minimize rippling of gels in rather thin breast tissue patients. Even in the breast reconstructive realm where there is even less overlying tissue, the push for pre-pectoral placement of silicone gels completely wrapped in acellular dermal matrix material is gaining favor to avoid muscle animation deformities. For the prospective patient reading this blog don’t be hampered by simply listening to your girlfriend who had implants some fifteen years ago and tells you to have a augmentation with saline under the muscle because that is what she had and she is happy. I applaud you for exploring implant options and encourage you to seek modern options with less long term negative outcomes with sub-glandular placement of textured implants.
Why avoiding muscle coverage in augmentation mammoplasties results in fewer long term complications was last modified: July 30th, 2018 by admin
Remodel – Customized Breast Enhancement – Let the Lucas Center, Plastic Surgery offer you a customized approach.
Are you a breast augmentation patient who either had surgery in the late 1990’s during the silicone false claim crisis or a patient who was misled into thinking that saline is an equivalent to the modern silicone gel implants? Or you were a fan of the 1990’s Bay Watch series and at the time felt that Pamela Anderson’s breast shape and size was the ideal standard. Just like houses with bathrooms and kitchens that seem dated after ten to fifteen years, requiring attention to remodeling to keep the house fresh and modern, so are breast enhancements. Stylistic changes and technology advancement of breast implant materials and fat grafting have come a long way, making your old decisions for your breast enhancement seem out of date and behind the times. Just like clothing styles and cars from the 1990’s seem dated now, so is the oversized sagging breast with saline implants, complete with rippling and pleating requiring an industrial strength bra to keep them in place. Ladies you don’t have to compromise any longer. Does your kitchen and bathroom still have brass fixtures? Then you should not have to put up with these heavy oversized misshapen breasts that are neither comfortable nor stylish. Consult a board certified plastic surgeon to review your options today.
Options not available 10-15 years ago.
First and foremost a modern plastic surgeon who has kept up with the current techniques and evidence based medicine related to breast enhancement will perform a complete tissue based diagnosis of the breast. Gone are the days hopefully of a surgeon standing in front of you without any measurements and eyeballing a one size fits all approach and telling you he or she will make you a “D” cup and you will love it. The facts are the 1990’s approach of shoving in multiple sizers or placing the largest possible smooth round saline implant under the breast without individualizing fit based on the patients breast tissue parameters lead to a revision rate of breast enhancement of 25% which manufacturers submitted to the FDA in the early two thousands. If gallbladders and knee replacements had that high of a revision rate insurance companies and Medicare would have a moratorium on the procedures. Fortunately our though leaders in plastic surgery have evaluated and re-engineered the procedures to minimize complications of capsular contracture, incorrect size placement, and avoidance of soft tissues being permanently thinned and distorted requiring complex revision procedures to correct poor outcomes. Most importantly the surgeon needs to determine the correct diameter of the devise both in width and height. The soft tissue thickness of the upper and lower pole (area above and below the nipple) is important as well as the tissue length from the fold to the nipple-areolar complex. The overall geometry of the chest and breast bone need to be noted requiring modification of procedures. It does not take an engineer to understand a women who is five feet tall and one hundred and ten pounds with a relatively short breast fold to collarbone and narrow chest with minimal breast tissue cannot have the same implant placed as a five feet, nine inch tall female with one hundred and sixty pounds with a wide frame and a large “B” cup breast. Unfortunately some surgeons did feel this way and some still do detracting from a customized approach that minimizes revision rates and unhappy patients.
Three dimensional imaging such as the Vectra has revolutionized my patient education and consultation for breast enhancements. We can produce a very representative imaging of a women’s breast and torso and with computer simulation can demonstrate how any implant available in the United States can appear with your tissue parameters and allow the patient to see the proposed outcomes before a decision is made. This avoids wrong size surgery and allows patient expectation to be matched thus avoiding revision surgery. However the technology does not exist to provide this information if a breast already has an implant. This simulation also allows patients to see the limitations of an implant alone based on enhancement depending upon the individual’s soft tissue or bony deficiencies. This is where the discussion of fat grafting can be very beneficial to hiding the anatomic variances such as wide sternums that produce wide cleavages to provide an improved outcome and patient satisfaction. We can also demonstrate using a slightly smaller implant which has less weight and drag on poor quality soft tissue and supplementing the overall volume with large volume fat grafting to minimize implant malposition due to failure of soft tissues holding the implant in place.
Breast implants themselves have evolved over the last few decades. Today plastic surgeons can offer patients more options in size, shapes, and types of silicone than ever before also allowing for a more customized approach. I particularly have found the fifth generation silicone gel implants (Gummy Bears) to be particularly useful in petite women and very tall, thin women to exploit the positioning of the implant with differential heights and widths to maximize outcomes. I never use saline implants because they put too much strain on tissues, have excessive rippling, only can function as a round devise and can spontaneously deflate creating emergency surgical situations for patients. Based on clinical evidence, texturing of the implant can reduce capsular contracture, minimizing migration of the devise laterally over time and can maintain pocket size better than a smooth devise. Downsides include late seromas (fluid collections) and possible linkage with a very rare but easily treated form of implant related lymphomas. In my mind the benefits outweigh the small risks with texturing.
Lastly, the techniques of the actual surgery have evolved in the last ten years. These techniques include more precise, less traumatic dissections of the breast pocket, avoiding biofilm (a leading cause of capsular contracture) by minimizing the manipulation of the pockets with implants, and no touch techniques with the surgeon’s hands or patients’ skin on the devises that can minimize revision rates and improve outcomes.
In conclusion if you are a breast enhancement patient and are less than satisfied with your outcome don’t learn to live with compromise explore the modern day breast augmentation procedures available at board certified plastic surgeon’s offices around the country. Remember cell phones, cars, computers and styles have all rapidly evolved for the better compared to the 1990’s refresh yourself you will be glad you did.
Fashion trends change, and so do accepted ideals for body appearance. The influences of Latin culture on American norms have triggered an explosion in the demand for buttock enhancement with fat grafting, which was first popularized in Brazil. Another trend patients are requesting is a more conservative and natural looking breast enhancement. A recent survey in California found that women are not looking for an oversized breast enhancement and desire a more subtle appearance. This is a healthier choice for women to choose.
Due to the prevalence of evidence-based medicine and FDA demand for data on silicone gel breast implants, findings indicate that revision breast surgeries after a primary augmentation mammoplasty are as high as 25 percent. The main reason for these revisions is capsular contracture, but size change is a factor. Thanks to the work of Dr. John Tebetts, Bill Adams and Dr. Dennis Hammond, the concept of calibrating the correct implant size for a given individual based on breast tissue characteristics allows for customization and has reduced revision rates for surgeons who incorporate these findings into their practices.
The idea of putting the largest possible implant into a women’s breast is fraught with potential complications including excess stretch on the tissues leading to thinning of the breast which may result in increased prominence of rippling of the implant, as well as mal-positioning of the device either laterally or inferiorly. This causes an unsightly aged appearance of the breast. The cost of revision can be high if treatment plans include the need for added soft tissue support utilizing acellular dermal matrices or a silk textile mesh to restore soft tissue support of the implants.
Today is a very exciting time in the field of augmentation mammoplasty, because we surgeons have a wide variety of shapes and sizes and silicone gel consistencies to choose from to provide customized results for our patients.
I strive to deliver a primary augmentation of the breast with a correct implant that is sustainable by the body to provide a long-lasting aesthetic result free of revision until the integrity of the implant has failed.
I think in terms of the height and width and projection of the breast independently and choose styles and shapes to match my patient’s desired outcome. I never want people to say that all my breast augmentations look the same. Just as all faces are unique and different, so are breasts. I want to make an individual’s breast look and feel as attractive as possible with long-lasting results. Proportionate breast enhancement is key to achieving these results.
Furthermore, now fat grafting can be performed simultaneously with implant placement, allowing surgeons to correct volume and shape asymmetries, as well as fill in spaces where an implant cannot be placed, such as the cleavage region and the chest wall/implant interface.
If you’re considering an augmentation mammoplasty, take a look at a three-dimensional analysis imaging of yourself. Then discuss your tissue type and pre-existing breast tissue with your surgeon, who will devise a plan to make a customized result that will look attractive and proportional with your frame. A skilled board-certified plastic surgeon will choose an appropriate implant with or without fat grafting to highlight your own unique figure with long-lasting results.
Why less is more: the trend toward natural looking breast enhancement was last modified: December 7th, 2016 by admin
I recently attended the 2015 Atlanta Breast Symposium sponsored by the Southeastern Society of Plastic and Reconstructive Surgeons. This annual conference is the premier event for new products and technology specific to breast surgery. The symposium features live procedures, scientific paper presentations and follow-up exhibits from the previous year’s live surgeries. Each year, I spend time with industry colleagues exploring what’s on the horizon, so I can implement what’s immediately applicable to my practice.
Takeaways from the 2015 Symposium:
Surgeons are seeing increased efficacy and safety of simultaneous breast augmentation using implants with fat grafting. This composite augmentation of the breast yields both improved aesthetic outcomes as well as enhanced long-term results. Fantastic breast augmentation is created when there’s appropriate soft tissue coverage and support of the implant. I was already an advocate of fat grafting to revise existing implants. Going forward, I’ll offer implants with simultaneous fat grafting to my patients for an even more natural silhouette and better support.
Textured, shaped highly cohesive silicone gel implants were a hot topic at this year’s symposium. I was an early adopter of these breast devices and continue to expand their use on a case-by-case basis. They’ve proven to be very beneficial in providing optimal results in certain circumstances for both primary and revision surgeries in aesthetic and reconstructive procedures.
The debate over the use of smooth versus textured implants continues. Many surgeons prefer a smooth round silicone implant, because the experience with textured saline implants was not favorable. However, European surgeons have utilized textured silicone for many years with good success. My experience with the textured, shaped highly cohesive gel devices has been very rewarding. It’s my opinion that the texturing may benefit women who might be at risk for the implants drifting from their ideal position. Several papers were presented that support my clinical opinion.
The future is bright for women who choose breast augmentation or reconstruction after breast cancer. There are more options available than ever before to achieve your desired aesthetic. I look forward to discussing these exciting new techniques and products with you.
There are many different kinds of breast implants in the market right now, and it can be confusing for anyone to know what is best. That is why Dr. Lucas is here to help you sift through all the clutter and introduce the latest breast implant.
The FDA recently approved the Natrelle® 410 highly cohesive, anatomically shaped silicone-filled breast implant for use in augmentation, breast reconstruction and revision surgeries. These gel implants provide an important new alternative to traditional round implants for women. It is designed to mimic the slope of the breast and hold its shape over time while remaining soft to the touch.
The FDA approval of the Natrelle® 410 gel implants was based on an extensive review of various data and studies, including pre-clinical device testing and clinical data from Allergan’s 10-year prospective, multi-center pivotal study. It involved nearly 1,000 women who have undergone breast reconstruction, augmentation or revision surgery.
During your consultation for breast surgery with silicone gel implants, Dr. Lucas can discuss which implant options are right for you. Natrelle® 410 implants with the highly cohesive gel offer a shaped profile alternative to a round devise which might be right for you.
If you have any questions about this breast implant or any others, please contact The Lucas Center of Plastic Surgery at 865-218-6210.
Dr. Jay Lucas is a board-certified plastic surgeon located in Knoxville, TN. He has a decade of experience performing a variety of cosmetic surgeries, and his unique educational background at some of the nation’s most prestigious medical centers allows him to perform cutting-edge plastic surgery procedures for his patients. This includes face lifts, breast augmentations, tummy tucks and rhinoplasties.
Natrelle 410 Breast Implants was last modified: December 12th, 2016 by admin
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