techniques in cosmetic surgery breast augmentation ......techniques in cosmetic surgery breast...

Techniques inCosmetic Surgery

Breast Augmentation: Choosing the OptimalIncision, Implant, and Pocket PlaneDavid A. Hidalgo, M.D.New York, N.Y.

A retrospective study of 220 patients was performed toreview surgical design in breast augmentation. Three spe-cific issues were studied: incision site, implant variables,and pocket plane selection. The influence of these threefactors on aesthetic results in both primary and secondarycases was the focus of the analysis. No attempt was madeto address long-term issues such as capsular contracture orsaline implant deflation rates. In 77 primary augmenta-tion patients and 80 unilateral augmentations for symme-try in breast reconstruction, there were the following un-toward results: 11 revisions for unilateral malposition,change to a different implant shape, or change to a largerimplant size; four deflations of saline implants requiringreplacement; and four conversions of saline to silicone gelimplants. In 63 secondary cases, there were two hemato-mas and two infections requiring implant removal andsubsequent replacement. Operative technique in breastaugmentation is described, as are recommendations foreach of the options associated with the three variablesstudied. (Plast. Reconstr. Surg. 105: 2202, 2000.)

The design of breast augmentation proce-dures is almost entirely determined by threevariables: the selection of incision location, thepocket plane for implant placement (eithersubpectoral or completely subglandular), andthe appropriate implant. Implant-related vari-ables include size, shape, shell texture, fillersubstance, and final implant fill volume in thecase of saline implants. There is no incontro-vertible evidence that supports the superiorityof one combination of choices over another.However, certain anatomic configurations inprimary cases as well as certain problems pre-sented in secondary cases are best treated witha specific combination of options that may dif-fer from a usual preferred approach. Thisstudy is a retrospective review that seeks toestablish the optimal indications for each of

three variable options as they relate to specifictypes of augmentation problems.

PATIENTS AND METHODS

A total of 220 patients underwent breast aug-mentation between 1991 and 1998. This in-cluded 77 primary augmentations performedfor aesthetic purposes, 80 unilateral augmen-tations performed as symmetry procedures inbreast reconstruction, and 63 aesthetic aug-mentation patients who required secondary re-moval and replacement of breast implants. Thefollow-up period ranged from 1 month to 6years. A meaningful average follow-up periodwas difficult to determine because many pa-tients did not return for follow-up after severalpostoperative visits. Therefore, no attempt wasmade to determine overall patient satisfactionor the incidence of capsular contracture, topicsthat are not the focus of this study and havebeen reported elsewhere previously.1–5

Operative Technique

Preoperative preparation includes the ad-ministration of intravenous antibiotics, pad-ding, securing the head to stabilize the patientfor sitting up later in the procedure, and se-curing the arms either abducted on armboards(transaxillary approach) or taped across thelap (periareolar or inframammary incision ap-proach). Monitored sedation anesthesia is typ-ically used. The intercostal nerves are individ-ually blocked with 0.25% bupivacaine. Each ofthe lateral intercostal nerves associated withribs two through eight is injected at the loweredge of each rib, and also the interspace of ribs

From the Division of Plastic Surgery at Cornell University Medical College. Received for publication January 5, 1999; revised July 22, 1999.

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two through six approximately 1 cm lateral tothe sternocostal junctions. A total of 30 to 40cc is used. This nerve block is not difficultbecause these patients are usually thin andthe landmarks easily palpable. It contributessignificantly to the patient’s comfort postop-eratively. The incision, the inframammarycrease, and the soft tissue in the region of theinferomedial origin of the pectoralis majormuscle are injected with 1% lidocaine withepinephrine.

After the incision is made and the pocketdeveloped, the patient is placed in a sittingposition, and a saline sizer is inserted. A sizer iscritical to accurately determine the proper im-plant size. There is usually a narrow volumerange that achieves the desired aesthetics, andthis is established by adjusting the sizer volumeand observing the effect. Exceeding the rangethat provides adequate augmentation withoutdistortion results in a less natural appearance.Distortion results from a combination of exces-sive volume for chest and overall patient pro-portions, excessive implant diameter, and con-vex upper pole shape (Fig. 1). Selecting thecorresponding implant size in the case of sili-cone gel implants must be precise because of

the fixed size of these devices. Selecting themost appropriate saline implant size shouldtake into account whether or not filling theimplant beyond its stated shell size is desired.In very thin individuals, round saline implantscan be used with minimal rippling if they are“overfilled” as much as 15 percent higher thanthe stated implant size (Fig. 2). This is themaximum amount that will not cause the im-plant shape to be conspicuous or its consis-tency too firm. The implant size selectedshould take into account the amount of “over-fill” desired so that the final volume approxi-mates closely the sizer-determined volume.Shaped implants become even less “anatomic”with overfill and resemble more a lozenge thana “teardrop.” Therefore, they should be filledbeyond their stated shell size more conserva-tively if at all. Final fill volume with implantsused for combined augmentation and mas-topexy is less critical because these patientstypically have enough native breast tissue tohide the implant well even if filled to less thanthe stated implant shell size.

The medial aspect of the pocket is developedas much as desired before the lateral aspect isenlarged. The latter is generally done conser-vatively to prevent lateralization of the im-

FIG. 1. Implant size (diameter) and fill volume are key determinants of breast appearance.(Left) A natural result with a flat upper pole was achieved by a modest submuscular augmentationusing smooth-shell 200 cc round implants filled to 210 cc on both sides. Preexisting breast volumeestimated at 80 to 100 g. (Right) A distorted and unnatural appearance is seen in this patient whohad approximately 75 g of breast tissue preoperatively. Implant diameter is excessive andcontributes to a tight appearance with a convex upper pole. Textured-shell 360 cc saline implantswere used with a final fill volume of 390 cc.

Vol. 105, No. 6 / BREAST AUGMENTATION 2203

plants. Subpectoral implant placement re-quires partial detachment of the pectoralismajor origin. This is usually limited to the in-feromedial aspect of the muscle. Excessive de-tachment superiorly can contribute to symmas-

tia or dimpling of the overlying skin withmuscle contraction.

Placement of the implants usually requireslowering the inframammary crease. The creaseshould always be lowered enough so that the

FIG. 2. Transaxillary submuscular breast augmentation in the extremely thin patient.Smooth-shell 250 cc round saline implants were placed with a final fill volume of 288 cc on bothsides. A guideline of 15 percent volume overfill is reliable to provide maximum protection againstpostoperative rippling while retaining reasonably soft breast consistency. This patient subse-quently requested an exchange for silicone gel implants, which did not yield a significantlydifferent result.

2204 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2000

horizontal midaxis of the implant is centeredon the nipple. It is obvious that the larger theimplant diameter the more the crease will haveto be lowered. Lowering the crease excessivelyto accommodate an overly large implant makes

inframammary crease asymmetry or a “double-bubble” deformity more likely to occur. There-fore, this should be taken into consideration indetermining the best implant size and volumefor a particular situation. An inframammary

FIG. 3. Circumareolar skin excision with and without mastopexy as an adjunct in breastaugmentation. (Above) Areolar repositioning was not elected in this patient who preferred mildasymmetry and ptosis to additional scars. Indications for mastopexy in borderline cases shouldbe conservative, as most patients seem indifferent to areolar position asymmetry in the absenceof true ptosis of the gland. (Below) Circumareolar skin excision of 5 cm in diameter was designedon the right side to raise the areolar position. It was combined with excision of 20 g of periareolarbreast tissue in this case of mild tubular breast formation.


crease that is inadvertently lowered too muchduring a transaxillary approach can be cor-rected immediately by placing an external bol-ster suture(s) at the appropriate level whilemanually displacing the implant superiorly.This type of suture should include the deepsoft tissue of the chest wall and is left in placefor as long as 2 weeks postoperatively.

Antibiotics are placed in the implant butsteroids are not.6 The implant is rinsed withdilute betadine before insertion.7 A closed sys-tem of fluid administration is used to fill theimplants.

Certain adjunctive procedures are helpful tofurther improve aesthetic results. These includenipple reduction and adjustment of areolar di-ameter. Nipple reduction can be accomplishedeither by excising skin circumferentially as muchas 50 percent of the nipple height. Simply closingthe resultant defect decreases nipple projection.Nipples that are prominent and wide can bereduced by partial vertical excision. Patients mustbe advised about the possible impact on sensa-

tion of these techniques, although clinical expe-rience has shown little adverse effect. Areolardiameter can be reduced by intra-areolar exci-sion. However, circumareolar scars are an eventrade at best for areolar diameter reduction, andthis method is not recommended for routineuse. It is best reserved for unilateral applicationin the rare case where there is a considerableside-to-side diameter discrepancy. Skin excisionsthat are less than 1 cm wide around the circum-ference of the areola usually are associated withexcellent quality scars. Circumareolar skin exci-sion, possibly combined with intra-areolar exci-sion, is useful in cases of tubular breast hypomas-tia where there is considerable pseudoherniationanteriorly with prominence of the areola andassociated gland ptosis. In cases of either circum-areolar or intra-areolar excision, a pursestringsuture of nonabsorbable material such as 2-0clear nylon on a Keith needle (Ethicon) is rec-ommended to stabilize the decreased areolar di-ameter.

Position asymmetry of the areolae is com-mon preoperatively, and the placement ofbreast implants often magnifies any preexistingdiscrepancy following augmentation. Thebreast implants should always be placed sym-metrically, even though the areolar positionmay be different on each side. Most patientstolerate naturally occurring asymmetry withoutconcern so that correction, with its attendantscars, should not be advocated unless the de-gree of asymmetry is expected to be consider-able (Fig. 3). It is possible to raise the areolarposition slightly with a vertically eccentric skinexcision design, although it becomes morechallenging to precisely control areolar shapeas the perpendicular diameters of the skin ex-cision design increasingly differ. More signifi-cant areolar position issues such as ptosis mayrequire concurrent mastopexy, a procedurebeyond the scope of this discussion.

Postoperatively, it has proved useful in casesof submuscular augmentation to have the pa-tient wear an adjustable strap across the upperpole of the breasts for as long as 6 weeks (Fig.4). This prevents upward migration of the im-plants and ensures that the lowered inframam-mary crease remains at the desired height. Thispractice is most helpful in the case of transax-illary augmentation and should be used withcaution when an inframammary incision hasbeen used. The strap tension may require ad-justment, and the patient should be seen atappropriate intervals to monitor implant posi-

FIG. 4. Adjustable straps are useful postoperatively to pre-vent upward migration of breast implants. They are indicatedprimarily in patients with submuscular implants placedthrough an axillary incision, although they are helpful in anypatient in whom the inframammary crease requires signifi-cant lowering.


tion and strap tension. Patients are not in-structed to massage the implants.

RESULTS

The most common options selected for pri-mary augmentation (both aesthetic and recon-structive) in this study included transaxillaryapproach, submuscular pocket plane, andsmooth saline implants. Other combinationswere far less common and were selected ac-cording to the guidelines described below. Themost common options selected for secondaryaugmentation included periareolar incision,no change in pocket plane, and placement oftextured silicone gel implants.

The significant number of secondary cases inthis study support the notion that breast aug-mentation patients frequently pursue revi-sional surgery with another surgeon. There-fore, accurate follow-up of both primary andsecondary cases is difficult, and the results re-ported here are likely to underestimate thetrue incidence of revisional surgery. The pri-mary aesthetic breast augmentation patientgroup included seven that required adjustmentof implant position on one side,3 change fromround to shaped implant,1 or bilateral increasein implant size.3 There were four patients whounderwent exchange of implant(s) for prema-

ture deflation of saline implants, all occurringwithin 3 years of placement. This included onepatient who had premature bilateral deflationof shaped implants with failure occurring at thesuperior-most aspect of the implant on bothsides. There were two patients augmented withsaline implants that opted for replacement with asilicone gel type. There were two primary con-genital asymmetry patients who chose to have asecond procedure years later for further im-provement. In the unilateral augmentationgroup for breast reconstruction, there were fourrevisions to further improve symmetry. Two pa-tients in this group also opted for exchange ofsaline implants for a silicone gel type. There weretwo hematomas requiring evacuation in the sec-ondary aesthetic group, and both occurred inpatients where the pocket plane was convertedfrom subglandular to subpectoral. Two second-ary patients required removal of implants forinfection with later replacement.

DISCUSSION

Incision Selection

Incision choices in breast augmentation in-clude axillary, inframammary, periareolar, andmore recently, periumbilical. There are multi-ple factors that influence incision selection

TABLE IIncision Options*

Factor Axillary Periareolar Inframammary Periumbilical†

Implant planeSubmuscular 1 1 1 2Subglandular 2 1 1 1

Implant typeSaline round 1 1 1 1Saline shaped 2 1 1 2Silicone round/shaped 2 1 1 2

Preoperative breast volumeHigh (.200 g) 1 1 1 1Low (,200 g) 1 1 2 1

Preoperative breast base positionHigh 1 1 1 1Low 2 1 1 1

Breast shapeTubular 2 1 2 2Glandular ptosis 1 1 1 1Ptosis (grade I–II) 2 1 2 2

Areolar characteristicsSmall diameter 1 2 1 1Light/indistinct 1 2 1 1

Inframammary creaseNone 1 1 2 1High 1 1 2 1Low 1 1 1 1

Secondary procedure 2 1 1 2

* (1) indicates applicable; (2) indicates not generally recommended.† Included for completeness but not generally recommended.


(Table I). Each patient presents with certainanatomic variables that suggest one or morechoices as superior options. It is best not to relyrigidly on one incision type.

Periareolar incisions are the most versatile.

They allow central access to the implant pocketand are compatible with either muscle planeand all types of implants. They are the bestchoice when it is necessary to lower the infra-mammary crease considerably (Fig. 5). They

FIG. 5. Periareolar subglandular augmentation. Preoperatively, this patient exhibited gradeII ptosis owing to an abnormally high inframammary crease. A periareolar incision providedcentral access to the implant pocket, allowing the inframammary crease to be lowered substan-tially but accurately. It was not obvious preoperatively which plane would be best. A subglandularplane was used after a trial submuscularly on one side proved aesthetically inferior. Smooth-shell300 cc round saline implants were placed with a final fill volume of 320 cc on the right and 340cc on the left. The patient’s photosensitive skin is an unrelated issue.


are a logical choice when concurrent mas-topexy may be required but is not certain pre-operatively. In these patients, a sizer is typicallyplaced and the breast shape previewed. Thismay prove to obviate the need for additionalincisions that a mastopexy would require, but if

not, the periareolar incision is simply incorpo-rated into the design. A periareolar incision isalso the best choice for cases of tubular breasthypomastia because it allows circumareolarskin and parenchymal excision should thisprove necessary. It is the incision of choice in

FIG. 6. This patient with low breast position, glandular ptosis, postpartum atrophy, andsignificant preoperative breast volume proved an ideal candidate for subglandular augmentationthrough an inframammary crease incision. Smooth-shell 350 cc round saline implants were usedwith a final fill volume of 375 cc on the left and 350 cc on the right.


secondary procedures that require either cap-sulectomy and exchange of old implants orcapsulorrhaphy to correct implant malposi-tion. The few contraindications to a periareo-lar incision are small areolar diameter or a verylight areolar color with indistinct margins. Avariant of the periareolar scar method notcommonly practiced is a small incision at the

base of the nipple. Although there may be ascar-concealing advantage to this approach, ex-posure is quite limited.

Inframammary crease incisions are popularand almost as versatile as periareolar incisions.They are an ideal choice in patients who havesignificant breast volume preoperatively andexhibit either postpartum atrophy or just glan-

FIG. 7. Transaxillary submuscular breast augmentation without endoscopy. Smooth-shell 275cc round saline implants were placed with a final fill volume of 300 cc on both sides. Note thatshaped implants are not required to establish a desirable upper pole contour. Most patientsseeking breast augmentation are good candidates for this approach.


dular ptosis (Fig. 6). These patients usuallyhave a breast base of appropriate diameter sothat the incision will not end up displaced fromthe inframammary crease following implantplacement. In most cases, the final scar is wellconcealed in a deep crease below a slightlyptotic breast. This incision is usually a second-ary choice when the inframammary crease iseither high or nonexistent. It is also not indi-cated in tubular breast hypomastia unless theareolar deformity is minimal and it proves nec-essary to add a skin flap to widen the breastbase at the inframammary crease.8

The inframammary crease incision is not asgood as a periareolar incision in secondarycases requiring capsulectomy or closing downthe superior portion of the pocket because it isat the periphery of the pocket as opposed to itscenter. In addition, wound closure is moreprecarious in terms of either implant punctureduring closure or exposure postoperativelygiven that the weight of the implant pressesagainst it and the soft-tissue covering at theincision may be minimal. It is not unreason-able in some secondary cases where there arepreexisting inframammary incisions and eitherthick capsules or severe deformity to consider aperiareolar incision to optimize exposure and

thereby improve control of the procedure. Theinframammary incision is also not the bestchoice for patients undergoing unilateral aug-mentation as a symmetry procedure in breastreconstruction. In these cases, it increases theoverall scar burden on the chest and may com-promise lower skin-flap circulation should amastectomy be required on the augmentedside in the future.

The axillary incision is applicable to mostcases of hypomastia that do not have morethan grade I ptosis (Fig. 7). Its obvious appealis that there is no scar on the breast.9–11 Thisapproach does not require endoscopy, al-though there is evidence to suggest that theprocedure is more accurate when it is used.12

Whereas many patients require reassurancethat the axillary scar will not be visible and willbe of good quality, this routinely occurs. It is anideal choice in patients having a low preoper-ative volume and high breast position on thechest wall, those with small diameter areolae,and those with no inframammary crease. Likethe inframammary crease incision option, anaxillary incision is an excellent choice forwomen with high preoperative breast volumewho only require a small implant primarily toimprove the upper breast contour. This inci-

FIG. 8. This patient presented with previously placed shaped implants (McGhan style 468).(Left) Although subglandular location contributed to the odd appearance, this photographillustrates that “anatomic” implants do not guarantee a natural result. Implant size, fill volume,muscle plane, and implant volume together are more important variables than implant shapein most cases. (Right) Postoperative appearance following submuscular placement of texturedround silicone gel implants through a periareolar incision.


sion is not practical for subglandular augmen-tation; fortunately, breast characteristics thatsuggest a subglandular approach usually favorother incision choices. An axillary incision ismore challenging in patients with long chestsand low breast position, but this scenario doesnot constitute a contraindication to thischoice. Tubular breast hypomastia is a contra-indication for an axillary approach unless thedeformity is truly minimal.

Secondary procedures in breast augmenta-tion are usually a contraindication to an axil-lary incision approach. A simple exchange ofimplants through the original axillary incisionrequires endoscopy and can be challengingbecause multiple capsulotomies are often re-quired.13 A second incision, such as a periareo-lar type, is well tolerated as an alternative bypatients because it still constitutes the first scaron the breast. However, endoscopy is preferredby some for both primary and secondarytransaxillary breast augmentation. Its propo-nents claim that the additional time involvedwith use of the endoscope is not significantonce experience is gained, and that implantmalposition problems in primary cases are lessfrequent when an endoscope is used.14

The periumbilical approach has been devel-oped recently with its chief advantage being asingle inconspicuous scar located at a distancefrom the breasts.15 This method has many dis-advantages, which include poor access to theimplant pocket, inability to create a subpec-toral pocket, inability to use a silicone gel pros-thesis, inability to use a shaped prosthesis, andthe need for a second incision for revision orimplant replacement. It is not applicable tomore complex conditions such as tubularbreast hypomastia or other situations requiringalteration of nipple-areola complex position orshape. Its true value in breast augmentationremains to be established.

Implant Selection

Implant variables include filler type, shape,surface texture, and volume. Silicone gel im-

plant use in the United States is restricted tosecondary applications and very selected pri-mary cases. The latter includes patients requir-ing concurrent mastopexy or undergoing treat-ment for a congenital deformity. The majorityof women who seek primary augmentation aretherefore currently not candidates for siliconegel implants.

Silicone gel implants are commonly used toreplace old silicone gel implants. Most patientswho have had these devices for a long time areless concerned about alleged safety issues andare generally not pleased with the consistencyof saline implants nor as accepting of theirspontaneous deflation risk. Silicone gel im-plants are also used to convert saline-implantaugmentation patients who have unacceptableresults because of their thin body habitus,which makes the implant shape and ripplesobvious. Silicone implants are available withmore “anatomic” shapes, but these are likely toprove more useful for breast-reconstruction ap-plications.

All implants are available with either smoothor rough shell texture. There are several stud-ies that support the claim of decreased capsu-lar contracture with textured implants.1,7,16–19

Most practitioners prefer this surface type withsilicone gel implants, but it is believed thatripples are more common and more extensivein textured saline implants compared withsmooth shell types.20 Therefore, smooth shellsaline implants are usually selected for primaryaugmentation in thin patients, the most com-mon type. Textured saline implants can beused without disadvantage in patients withhigher preoperative breast volume, such asthose undergoing augmentation with mas-topexy. Another good indication is a small vol-ume augmentation intended primarily to fillout a flat or depressed upper pole in patientswith otherwise satisfactory breast volume.

Adjustable implants offer the prospect ofchanging implant volume postoperatively.21 Al-though this is an attractive feature, it should

FIG. 9. Secondary augmentation. (Above, left) Typical appearance of submuscular augmentations with capsular contracture. Thebreasts are full superiorly, and flat and ptotic inferiorly. (Above, right) The appearance is improved following replacement ofnine-year-old silicone gel implants with slightly larger textured-shell round saline implants in the same submuscular pocketfollowing capsulectomy. (Center, left) Typical appearance of subglandular implants with capsular contracture. The implantsremain low, but there is a characteristic shelf effect where the implant meets the chest wall superiorly. (Center, right) Theappearance is improved following replacement of 10-year-old stacked polyurethane-covered gel implants with a slightly largersize silicone gel implant placed in the same subglandular plane following capsulectomy. (Below, left) Visible subglandular salineimplants with rippling. (Below, right) Appearance following conversion to a submuscular plane and exchange of saline implantsfor silicone gel type.


not be necessary in most cases because it ispossible to accurately select the appropriateimplant volume with the use of a sizer intraop-eratively. It would tend to make postoperativecare unnecessarily complex if this option wereto be routinely offered to all patients. There isalso the need to remove a subcutaneous re-mote valve later.

These devices may be appropriate for theunusual situation where a wide range of vol-ume looks appropriate and the patient cannotclearly communicate her goals preoperatively.In this study, only a few patients required anadditional procedure to change implant size.

Shaped or “anatomic” implants may havemore conceptual superiority to round implantsthan they actually offer in practice. The typethat is applicable to breast augmentation has avertical axis longer than the horizontal axisand has been successfully marketed by themanufacturer to prospective patients as havinga natural, “teardrop” shape. The majority ofbreast augmentation patients are still bestserved by conventional round implants, al-though shaped implants are very successfulwhen applied to the quite different setting ofbreast reconstruction. A flat upper pole of thebreast can be consistently achieved with roundimplants when the appropriate size and finalfill volume are selected (Figs. 5 through 7). Apatient with a long chest and low breast posi-tion may constitute one of the better indica-tions for these particular devices. In most cases,the choice of shaped versus round implant isnot a dominant variable in the design of theprocedure. Selection of a shaped implant doesnot guarantee a successful outcome whenother important factors are ignored (Fig. 8).Shaped implants should be used with cautionin secondary cases where there is an estab-lished implant cavity with a retained capsule. Inthese cases, the implants may rotate on theiraxis during the postoperative period and resultin asymmetry requiring further surgery. It isalso not clear whether the stress forces thatultimately result in implant failure are equallydistributed in shaped implants compared withround implants. Bilateral premature failurewas observed in shaped implants at the top oftheir vertical axis in one patient in the studygroup.

Pocket Plane Selection

Subpectoral implant placement refers to par-tial muscle coverage underneath the pectoralis

major muscle. The implant is subglandular inits lower portion to a variable degree in thesecases. Complete submuscular coverage involv-ing mobilization of the serratus anterior mus-cle and anterior rectus sheath is useful fortissue expanders in breast reconstruction butnot appropriate for aesthetic breast augmenta-tion. Placement below the muscle is believed tocontribute to a decreased incidence of capsu-lar contracture.22–24 It is unequivocally helpfulin most patients to obscure superior pole im-plant shape and minimize the potential forperceptible ripples with saline implant use.Previously, with the widespread use of siliconegel implants in primary augmentation, sub-glandular placement was popular because itsimplified the procedure and minimized post-operative patient discomfort and recovery.

It has also been claimed that subpectoralimplant placement is advantageous for breastcancer monitoring, although the ratio of im-plant volume to breast tissue volume is likely amore important variable.25,26 Large implantswith a small native breast volume stretched infront impair mammogram interpretation farmore than the difference in effect betweensubglandular and subpectoral placement of anaverage size implant.

Subpectoral implant placement is indicatedin most cases of primary breast augmentationexcept for patients with normal body habitus(not excessively thin) who present with signif-icant postpartum atrophy and exhibit loosebreast skin, glandular ptosis, and significantresidual breast volume (more than 200 g perside). Subglandular augmentation in these in-dividuals more effectively restores shape with-out the risk of visible implant shape. Subpec-toral implant placement in these individualsmay fail to correct ptosis completely, whichmay result in an abnormal double breast con-tour.

Patients who present for secondary augmen-tation with capsular contracture often have acharacteristic appearance based on whethertheir implants are subpectoral or subglandularin location. Breast appearance with capsularcontracture and subpectoral implant place-ment usually has a convex upper pole owing tosuperior displacement of the implants. Thebreast is flat anteriorly and the native tissueoften ptotic (Fig. 9, above). Patients with capsu-lar contracture and subglandular implant loca-tion often maintain implant position but ex-hibit a sharp shelf-like contour deformity of


the upper pole of the breast, which is oftenquite striking (Fig. 9, center). In general, sub-pectoral implant location influences breast ap-pearance less than subglandular location whencontracture is only mild.

Secondary breast augmentation frequentlyincludes the option of changing subglandularimplants to a subpectoral location. This is gen-erally advisable in patients who have been pre-viously augmented with saline implants andpresent with visible implant contour with orwithout ripples (Figs. 8 and 9, below). Theseindividuals are commonly thin and may also bebest served with a conversion to silicone gelimplants at the same time to minimize thepossibility of residual deformity requiring yetanother procedure. Patients with old siliconegel implants commonly present with capsularcontracture, distortion, and a history of origi-nal subglandular placement. It is not necessaryto convert these patients to a submuscularplane in most cases. Plane conversion prolongssurgery, adding only questionable benefit, con-tributes to a more difficult recovery, and ismore prone to postoperative complicationssuch as hematoma. The procedure is tediousbecause the subglandular pocket must be oblit-erated superiorly with sutures, and this isadded to a procedure that may already belengthy because of the need to perform almosta complete capsulectomy.

In summary, a standardized approach tobreast augmentation may be suitable for mostpatients. However, optimal results will be con-sistently achieved if flexibility is retained insurgical design and if the combination of inci-sion, pocket plane, and implant is customizedwhen one is presented with specific anatomicvariants and secondary problems.

David A. Hidalgo, M.D.655 Park AvenueNew York, N.Y. [email protected]

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