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The aesthetic breast augmentation is one of the most common corrections in the aesthetic surgery. Many women think about the breast augmentation from the aesthetic and emotional aspects. The main reasons for the breast augmentation are: augmentating the size or shape of the breast (the cosmetic reasons), reconstruction after the removal of the breast because of the cancer, replacement of the existing old implants for medical or aesthetic reasons, and correction of the congenital deformities. In 99% of cases the augmentation is performed using the silicone mammary implants, while in only 1% of cases the implants are filled with the saline solution. The most modern types of silicone implants are filled with the cohesive silicone gel which is responsible for the lifelong stability of the implants shape (the “form stable implant”). The older types of implants were filled with the silicone oil, which is why the implants became deflated and changed the shape over the years, and had to be replaced after 10-15 years. Today’s modern implants, as we apply in our polyclinic, are lifelong. American companies such as “Natrelle” the manufacturer Allergan give lifelong guarantee on the quality of the silicone implants. Natrelle implants, as we usually apply in our polyclinic, are considered to be among the best in the world, and 60% of the total world implants market are Natrelle implants. The reason of wide usage of the above mentioned implants is the widest range of shapes and volumes of the silicone implants, then the most natural shape, and the smallest percentage of postoperative complications. The breast augmentation may be done earliest at 18 years of age. The ideal female candidate for the breast augmentation is older than 18 years, has the ideal or normal weight (the body mass index is between 20 and 25), the great tension and skin texture, the symmetrical smaller breasts whose nipples are oriented anteriorly (forward, when looking from the “en face” projection). There are 3 basic approaches to the breast augmentation:

–          Transaxillar (through the armpit)

–          Periareolar (through the lower half of the areola)

–          Inframammary (through the line which divides the lower pole of the breast and the anterior thoracic wall)

Transaxillar approach

It is the approach through the armpit area that contains many sweat glands which may contain numerous pathogenic bacteria, and which increases the possibility of the postoperative infection. The operational access is quite unpleasant for the operator because it disables good control of the formed pocket or possible bleeding. Most of the breasts that have been augmented by transaxillary approach look very unnatural, whereby the upper poles of the breasts are too prominent, and the nipples have an inferior or downward orientation. The scar from transaxillary approach is often hypertrophic and visible, and as such unacceptable. This approach is less used in the breast augmentation.

Periareolar approach

This approach is done through the semicircular incision around the lower pole of the areola. It is indicated with women who do not plan the pregnancy because it unavoidably transects certain laciferous ducts, which can disrupt the function of breastfeeding. If the areola is smaller in diameter, then the implants of greater volume can not be placed into the formed pocket. The disadvantage of this approach is a relatively high frequency of numbness or hypoesthesia of the nipples which are erogenous zones (statistically 10-15% of the cases). The scar is sometimes very little visible, and sometimes it is very impressive, and below it persists the permanent bulge of the breasts (the “double bubble deformity”).

Inframammary approach

The inframammary approach is the world’s most used (75% of the surgeons use this approach). The incision is located in the inframamary fold which is located at the turn of the lower pole of the breast to the anterior thoracic wall. This approach allows maximum visibility of the formed pocket, the easiest way to insert implants into the pocket, the best control of halting bleeding or hemostasis, and is characterized by raising or elevation of the nipples for a few centimeters compared to the preoperative position of the nipples. In our polyclinic we prefer this approach that, we think, gives the best aesthetic results. The scar must be precisely located in the newformed inframammary fold which is situated slightly lower than the position before the breast augmentation. The final scar is minimally visible and very well hidden in the inframammary fold.

Procedure

The first step is preoperative examination and consultation which includes a detailed discussion on patient’s desires, ie breast augmentation. Personal and family history and data about the general and cardiac health and illnesses in the family must be thoroughly examined. The next step is explaining the types of silicone implants. After that an examination has to be done: measuring the distance between the pit on the top of the sternal bone and the nipple (SN-N distance), then measuring the dimensions of the mammary area that compares with the dimensions of the implants which a patient prefers. A very important part of the examination is the so-called  clinical “pinch” test, which very accurately determines the location of the pockets in which the implants will be inserted. Any breast asymmetries, including the asymmetries of the volume, shape and position of the nipple, must be carefully recorded and shown to the patient. In the end, a thorough inspection of the anterior thoracic wall is required for the possible detecting of the bone and cartilage deformities of the ribs and/or the sternal bone. The breast palpation can detect any possible irregularities in the breast tissue. The breast USD or mammography are not required routinely, although it is recommended to do these tests as a part of preoperative treatment. The surgery is almost always performed under general anesthesia.

Surgical procedure

One of the most important factors for achieving the excellent aesthetic results is the proper selection of the silicone implant for each patient, considering her wishes, dimensions of the mammary areas and any abnormalities and/or irregularities in the bone-cartilage sceleton of the pectoral girdle. Also, it is important to identify the location of the pockets to insert the implants: whether the pocket will be formed above or below the pectoral maior muscle. For this purpose a practical clinical test, or the “pinch” test, is used. The test is performed in the projection of the upper pole of the breast by a special measuring instrument- calliper. The soft tissue of the upper pole of the breast is encompassed with the calliper legs and maximally pinched. If the measuring instrument indicates that the maximum width of the pinched upper pole of the breast is larger than 2 cm, then we decide to form the pocket above the pectoral maior muscle. If the width of the tissue is smaller than 2 cm, then the implants should be placed in the pocket formed beneath the pectoral maior muscle (the so-called “dual plane technique”).

In the picture left the implant is inserted into the subglandular pocket formed between the gland tissue of the breast and the pectoral maior muscle (the “pinch” test is more than 2 cm). In the picture right the silicone implant is inserted into the submuscular pocket formed between the maior and minor pectoral muscle (the “pinch” test is less than 2 cm).

The preoperative “marking” is extremely important. “Marking” includes marking of the distance from the nipple to the highest point of the sternal bone (the “sternal notch – nipple distance”), then the current position of the inframammary fold, dimensions of the implant and the pocket in which the implant will be inserted, the planned inframammary incision, the medial line of the pectoral girdle. The dimensions of the implant are set in the accompanying brochures. The required distance between the breasts is about 3 cm at the level of the nipples. The dimensions of the pocket must be somewhat larger than the dimensions of the implant (about 1-1.5 cm) to prevent rotation of the anatomical implants in the postoperative period. Most of the patients have mildly to moderately asymmetrical breasts. Any asymmetry must be preoperatively noted, photo documented and shown to the patient. In our polyclinic we successfully correct all preoperative asymmetries, either by forming the symmetrical pockets to insert the implants or by using different volumes of the implants.

The application of the saline solution with adrenaline and lidocaine in the mammary areas. The aim of this solution application is achieving the shrinkage or vasoconstriction of the blood vessels and allowing bloodless work during the procedure as well as excellent analgesia (lidocaine) or the absence of pain in the early postoperative period.

After the precise preoperative measuring, the initial inframammary incision is located about 1 cm below the real submammary line (the line where the lower pole of the breast passes onto the anterior thoracic wall) and is long from 4.5 cm to 5.5 cm, depending on the volume of the implant that is planned to be inserted. The location and length of the incision are very accurately marked on the basis of detailed measurements of the pectoral girdle dimension before the procedure.

After the precise preoperative measuring, the initial inframammary incision is located about 1 cm below the real submammary line (the line where the lower pole of the breast passes onto the anterior thoracic wall) and is long from 4.5 cm to 5.5 cm, depending on the volume of the implant that is planned to be inserted. The location and length of the incision are very accurately marked on the basis of detailed measurements of the pectoral girdle dimension before the procedure.

After the complete formation of the pockets, the moist sterile gauze is put into the pocket for the compression of the pocket walls and achieving satisfactory hemostasis or bleeding control. After that follows the preparing of the same pocket on the opposite side.

Before inserting an implant, we regularly wash the pockets with antibiotic solution. We use a combination of antibiotics which covers all possible causes of infection. We adopted this procedure after visiting the top hospitals in Bristol and Stockholm. The reason is very important: the prevention of the capsular contracture or creating the firm scar capsula like an envelope around the implant. In numerous researches the latent or subclinical infection with the bacterium Staphylococcus epidermidis (the normal skin saprophyte) in the cases of the capsular contracture development is confirmed.

On the pictures is displayed an implant in the original sterile packaging, which is opened just before inserting the implant into the formed pocket. Previously, the implant was soaked in the antiseptic solution for surgical skin disinfection to allow easier insertion of the implant and additional prevention of infection.

Inserting of the implant into the pocket. The role of an assistant is very important because the proper holding of the hooks allows a surgeon quick and easy implantation. Thereby it is important that the process of inserting the implant does not take longer than 15 to 20 seconds, because too large manual manipulation of the implant, such as squeezing, can furrow the surface of the implant, which is later manifested as the breast surface irregularity.

Before inserting the implants, a drainage tube is set into the pocket. We believe that it is necessary to set the drainage tube for draining the bloody and serous contents from the pocket, because this process allows shorter duration of postoperative swelling and hematomas, and reduces the possibility for the emergence of the capsular contracture. In addition, setting up a drain for the removal of the excessive content from the wound prevents the creation of larger asymmetry in the breasts and, given that redon drain produces the negative pressure inside the pocket, minimizes the possibility of the postoperative bleeding. After that, the implants are inserted into the pockets and follows the closing of the incisions by sewing the envelope or fasciae of the pectoral maior muscle with the underlying muscle using the resorptive thread. Such a method of sewing allows the precise location of the new inframammary line which is lower compared to the preoperative position of the line. If the incision is located precisely in the new inframammary line, it is minimally visible. On every implant there are special tags on the front and back surfaces that allow surgeons excellent orientation and proper installation of the implants.

On the pictures above sewing of the subcutaneous layer with the resorptive sutures where the suture knots are directed towards the depth of the wound is shown. We pay great attention to precise setting of the subcutaneous sutures for the sake of adaptation of the incision edges, which is particularly visible in the right picture.

The final sewing of the skin with the permanent suture, which is set intracutaneously, below the skin, so only the lateral parts of the suture are visible. It is noticeable that the edges of the incision are very precisely and correctly adapted to one another, which ensures the minimal, barely visible scar. The scar is exactly set in the new inframammary line (the line where the lower pole of the breast passes to the pectoral girdle), which will make it almost invisible. The suture is removed after 2 weeks. The remaining two layers of the resorptive sutures will be resorbed after a few months.

The final covering of the wound with the sterile bend. We tend to hold wounds closed during the first postoperative week, and then the wounds are left uncovered, in order to allow the patient normal showering (the children’s baths are recommended because they do not irritate the incisions).

Postoperative period

After the surgery a patient is moved to the recovery room where she stays for the  next 24 hours. Antibiotic is applied intravenously 8 and 16 hours after the procedure, and perorally the next few days. In this way the postoperative infection possibilities are maximally reduced. A patient does not feel any postoperative pain, because the intramuscular injections of analgetics are being applied, while the painkillers can be taken during the next few days. Moistening the wound should be avoided during the first postoperative week. Bending the wound is done every two to three days during which the sterile bend is changed and the antibiotic spray or powder is locally applied. In the first few postoperative days a slightly raised temperature can occur (to 38°C– it is a common postoperative, resorption raised temperature), which is not necessary to cure. A patient should sleep on her back with a slightly hightened pillow during the next month. Immediately after discharging from the polyclinic, the patient sets a special bra which excelently stabilizes breasts and protects them from the external trauma. It is necessary to wear the bra during 24 hours in the next 4 weeks. We recommend strict avoidance of physical activity and/or physical manipulation of the breasts for at least 4 weeks. The patient has to beware the accidental kicks in the area of the breasts. Hematomas and swelling of the breasts and surrounding areas of the pectoral girdle can be most visible 2-4 days after the procedure, and they usually last for 2-4 weeks. We recommend taking the pills on the basis of pineapple during the first 4 postoperative weeks because they significantly accelerate the swelling and hematomas resorption. The sutures are removed after two postoperative weeks. The patients should not take aspirin during the first two postoperative weeks because aspirin encourages the creation of hematomas.

A special bra is shown that is used to stabilize and fix the mammary implants during the first postoperative month. The straps on the front of the bra must be placed in the projection of the upper poles of the breasts so that a natural pear-shaped form of the augmented breasts would be subsequently formed. The bra is especially designed to respond to all needs of fixation and protection of the breasts in the early postoperative period.

Complications

The aesthetic breast augmentation complications are quite rare. Possible complications include:

• infection (we did not have a single case so far)
• bleeding
• capsular contraction or creation of the firm scar envelope around the implant (possibillity smaller than 2 %)
• implant rejection possibillity (we never had such a case in our practice)
• breast asymmetry (it is possible to correct it later, except in the case of a big preoperative asymmetry)
• hypertrophic scars and keloids (very rarely, they can occur with people prone to creating hypertrophic scars and keloids; we did not have a single case so far)
• BIA ALCL (breast implant associated anaplastic large cell lymphoma)- very rare maligant breast tumor with good diagnosis
• BII (breast implant ilness)-very rare disease caused with breast implants, it’s manifested by painful parts on the body, exhaustion, slightly elevated body temperature, skin changes, etc.

APPENDIX

Silicone implants

The aesthetic breast augmentation is one of the most common corrections in the aesthetic surgery today. On the silicone implants market there are 2 basic types:

1. anatomical
2. round

We use only Motiva nano textured (smoothsilk surface) implants (mainly Ergonomix and Anatomical TrueFixation) i Polytech micro textured Mesmo and Microthane polyurethane implants (polyurethane implants are indicated in secondary or revision operations, and with patients who train body building, extreme sports, and everyday intense workouts).

Operacija povećanja grudi pomoću implantata može se izvršiti na tri načina: kroz pazuh, kroz donju polovnu areole, kroz brazdu koja dijeli prednji zid prsnog koša i donji pol dojke.

U ”Ordinaciji Ostojić” estetska operacija grudi najčešće se izvodi inframamarnom metodom gdje se implantat umeće kroz rez na brazdi između donjeg pola dojke i prednjeg zida prsnog koša (inframamarna brazda). Inframamarni pristup operacije povećanja grudi omogućuje najbolju preglednost formiranog džepa, najlakše umetanje implantata u džep i izuzetnu kontrolu zaustavljanje krvarenja i ostalih komplikacija pri zahvatu.

Prednosti ove metode su izuzetno nizak rizik od mogućih komplikacija za vrijeme operacije povećanja grudi kao i u postoperativnom periodu, podizanje bradavica za nekoliko centimetara u odnosu na preoperativni položaj, minimalna vidljivost, tj. odlična prikrivenost ožiljka u inframamarnoj brazdi i općenito vrhunski estetski rezultati i zadovoljstvo klijentica. Iz ovih razloga preferiramo inframamarni pristup.

Periareolarni pristup vrši se kroz polukružni rez oko donje polovine aureole. Ovaj pristup daje dobre rezultate, no postoje određeni nedostaci. Prije svega, periareolarna operacija povećanja grudi nije primjenjiva na pacijenticama koje planiraju trudnoću (ili žele ostaviti tu opciju otvorenu nakon operacije) jer se pri zahvatu ne može izbjeći presijecanje određenih mliječnih kanalića (samim time može se poremetiti funkcija dojenja). Nadalje, implantati većeg volumena ne mogu se umetnuti kroz rez ukoliko je areola manjeg promjera, dok je ožiljak od reza ponekad neprimjetan, a u nekim slučajevima izrazito vidljiv. Isto tako, u 10% – 15% slučajeva moguća je učestalost utrnulosti ili hipoestezije bradavica.

Transaksilarni pristup povećanja grudi implantatima vrši se kroz rez u pazušnoj regiji. Ovaj pristup povećanju grudi koristi se sve rjeđe. Ožiljak je vrlo često vidljiv, a često grudi koje su povećane ovim pristupom izgledaju neprirodno – gornji polovi dojke su previše naglašeni, a bradavice orijentiraju prema dolje. Veliki nedostatak pristupa je i činjenica da se u pazušnoj regiji nalaze brojne žlijezde znojnice koje mogu sadržavati patogene bakterije što povećava rizik od postoperativnih infekcija. Uz to, sam zahvat operateru otežava kontrolu formiranog džepa i eventualnog krvarenja.

Odabir vrste zahvata radi se kod preoperativnog pregleda povećanja grudi, gdje se pacijenticu dodatno detaljno informira o svim prednostima i manama pojedinog pristupa.