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MAMMARY IMPLANTS AND BREAST HYPOPHASIA
or AUGMENTATION MAMMOPLASTY
WITH IMPLANTS
DEFINITION, AIMS AND PRINCIPLES
Mammary hypoplasia is defined as a breast volume which is
insufficiently developed in proportion to the patient’s
morphology. It can be a pre-existing condition (small breasts
from puberty) or appear later, after substantial weight-loss, a
pregnancy followed by breast-feeding, or hormonal problems.
It can occur alone or be associated with ptosis, that is sagging
of the breasts and skin stretching and a lowered areola.
This insufficient breast volume is often a source of physical
and psychological distress for the patient. Breast
augmentation with implants is the solution to these problems.
The procedure can be carried out at any age above 18, below
this age the procedure is not advisable.
The implants used at present are composed of a shell and a filler. The shell is always made of silicone rubber, but the filler
can vary. The implant is termed ‘pre-filled’ when the filler was
inserted during the manufacturing process (gel and/or saline
solution). The different volumes are therefore fixed by the
manufacturer. Implants filled with saline solution are filled by
the surgeon who can adapt them to the patient to a certain
extent during the procedure.
NEW GENERATION PRE-FILLED SILICONE GEL IMPLANTS
These implants, which have now been used for over 40 years
have been proved to be safe and to be the best product for this
procedure since they are very close to the consistency of a
normal breast. There has been great progress in this domain
since the late 1990’s, any weak points have been eliminated.
They are made of soft silicone gel inside a strong
impermeable envelope of silicone rubber which can be rough
or smooth.
The most important points concerning the new generation of
implants, which ensure their safety, are the new improved
envelopes and the gel itself.
The shells, which are now stronger, prevent any leakage of
gel (which was a cause of capsule formation) and have much
greater resistance over time.
Cohesive silicone gel which has a thicker consistency will not
spread in case of rupture of the envelope.
Added to this increased reliability is the fact that this new
generation of silicone implants exists in different shapes,
making it possible to adapt them to individual needs. Thus we
find, in addition to the classic round implants, anatomic ‘teardrop’ shapes which can be higher, wider or more
pointed.
BEFORE THE PROCEDURE
After discussion between the patient and the physicien who
will have clearly explained the different options the best choice
for each case is agreed on during the preoperative consultation
taking into account all the relevant parameters ( height, weight,
pregnancies, breast feeding, body shape, body fat, size of the
existing breasts, muscle tone..).
After studying these parameters and anatomic features of the
patient, the surgeon will determine the plan for the operation.
This will also take into account his preferred technique and the
expectations of the patient and the positioning of the scars, the
type and size of implants, and the position of the implants
above or below the muscle.
HOSPITAL STAY AND TYPE OF ANESTHESIA
Type of anesthesia
This is usually classic general anesthesia, you will sleep
throughout the operation. Rarely ‘twilight’ anesthesia is used
(local anesthesia with intravenous sedation), this can be
discussed with the surgeon and anesthesiologist.
Hospital stay
One day in hospital is usually sufficient.
THE PROCEDURE
The incisions
- Peri-areolar approach (around the areola) the incision is
either below the circumference of the nipple or horizontal to
 the nipple (1&2).
- Axillary approach
The implant is inserted through a small incision situated in
the armpit (3), or in
- The inframammary approach
The incision is in the inframammary fold (4).
These incisions correspond of course to the position of future
scars which will thus be hidden in natural folds or lines.
The position of the implant
This can be in a pocket made in the breast tissue behind the
mammary gland and in front of the pectoral muscle, or
behind both the mammary gland and the pectoral muscle.
Additional surgery
In case of ptosis (sagging breasts, a lowered areola), it is
appropriate to associate a breast lift (mastoplexy) in general the
operation lasts one to two hours.
AFTER THE OPERATION
There can be pain for the first few days after the procedure,
particularly when the implant is large and/or placed behind the
muscle. In this case pain medication of the strenth necessary to
dull the pain, is prescribed for several days.
Even if there is no pain there will be a strong sensation of
tightness.
Swelling and bruising of the breasts, and difficulty in raising
the arms are frequent immediately after surgery.
The original dressing is removed a few days after the
procedure and is replaced by a lighter dressing, then an
elasticised bra can be recommended to be worn night and day
for a few weeks.
Five to 10 days convalescence is necessary before returning to
work.
Patients are advised to wait for one to two months before
practising any sports.
THE RESULT
This can be truly seen from two to three months after surgery,
the time necessary for the breasts to become softer and for the
implants to settle. The procedure will have improved not only
the volume but the shape of the breasts. The scars are usually
hardly visible.
Duration of results
The implants have their own life-span, but without
taking this into account the result of this procedure concerning
volume, is long-lasting.
DISAPPOINTING RESULT
The following problems can occur occasionally:
- asymmetry of the final volume in spite of the use of
different sized implants to correct the problem.
- Stiffness with insufficient softness and mobility
(especially with larger implants).
- An artificial appearance especially for very slim
patients, the upper limit of the implant is visible.
- The implant can be detected when touched especially when the thickness above the implant is reduced
(skin + fat + gland) and when the implant is large.
In cases where the patient is not satisfied with the result
certain problems can be corrected by revision surgery after a
few months.
FREQUENTLY ASKED QUESTIONS
Pregnancy/breastfeeding
After having this procedure there is no problem regarding
pregnancy either for the mother or the child, but it is
advisable to wait for six month safter surgery. Breastfeeding
is still possible in most cases.
Auto-immune disease
Many international research papers published on the subject
have shown that there is not a higher risk of contracting this
type of rare disease with implants compared to the general
female population.
Implants and breast cancer
To our knowledge at present we can affirm that breast
implants, including those filled with silicone, do not increase
the risk of breast cancer. However, during screening
techniques clinical examination and palpation can be
affected, especially in case of siliconoma or capsular
contraction. The presence of the implants can also make it
difficult to carry out and read routine mammographies.. It is
necessary to explain beforehand that you have implants.
Other radiological techniques can be used; echography, MRI
etc.
Furthermore, if there is doubt as to a diagnosis of breast
cancer you must be aware that more invasive exploratory
techniques may be used in order to be sure of the result.
How long will the implants last ?
Although it is true that some patients can keep their implants
for decades without major changes, an implant, whether filled
with silicone gel or saline, cannot be said to last for a specific
time, this is not a permanent life-long prothesis. A patient
with implants must expect them to be replaced at some point
in time, if the initial effect is to be maintained. It is
impossible to predict the life-span of an implant, of whatever
type, as this depends on wear which is variable.
This means that no guarantee can be given regarding their
life-span.
It should be noted however that the new generation implants
are far more hardwearing and reliable. The notion of
replacement after ten years is no longer justified, they only
need to be replaced if a problem is detected, or the patient
wishes to change their size or shape or to correct ptosis
Follow up
It is important to keep the appointments with your surgeon
during the weeks and months following the operation. After
this stage regular medical visits with, for example your
gynecologist, or for routine mammography will continue this
follow up. You must tell each physician that you have breast
implants.
POSSIBLE COMPLICATIONS
Breast augmentation with implants, although essentially an
aesthetic procedure, is nevertheless an operation, and this
implies that the risks inherent to any surgery apply here.
- Possible complications inherent to all breast surgery
A hematoma : blood can surround the implant shortly after
surgery. In case of heavy bleeding it is necessary to return to
the operating room to drain the blood and put a stop to the
bleeding.
Serous effusion : this means an accumulation of lymphatic
liquid around the implant. It is a frequent complication often
associated with considerable swelling., It gives rise to a
temporary increase in the volume of the breast or breasts. It
decreases gradually and disappears.
Infection : rare after this procedure. It can require more than
one course of antibiotics and the removal of the implant for
several months following drainage. After this time interval
another implant can be put in place.
Abnormal scar : formation the healing process is
unpredictable, and scars can be less discreet than expected.
They can be widened, retractile, hyper- or hypo-pigmented,
hypertrophic, or rarely, cheloid.
Sensory changes : this is frequently found in the first few
months but usually diminishes over time; Rarely however, a
certain degree of dysesthesia (heightening or diminution of
sensitivity) can persist around the areola and the nipple.
Galactorrhea/milk secretion : very rare cases of unexplained
postoperative hormonal stimulation have been reported,
giving rise to milk secretion which sometimes collects around
the implant.
Pheumothorax : very rare, has specific treatment.
- Specific implant-related risks
Wrinkling or rippling : the implant is soft and natural, and for
this reason the outer envelope of the implant can form
creases, which can be palpable or visible in certain positions
under the skin, giving a ‘ripple’, effect.
Capsular contractures : it is a normal physiological reaction
that a fibrous shell should develop around an implant. A
normal reaction to the presence of a foreign body in the
organism is to isolate it from the foreign body with a
hermetic membrane called a ‘periprosthetic capsule’.
Normally this membrane is thin, supple and imperceptible but
the reaction can increase and the capsule can thicken, become
fibrous and contract exerting pressure on the implant, it is
then known as a ‘capsule’ There are four stages of hardening
that range from a normal undetectable aspect to severe forms
giving hard, round, immobile breasts which can be painful.
Capsular contraction can follow infection or a hematoma, but
often has no determined cause, resulting from unpredictable
organic reaction.
Surgical techniques have made great progress in recent years,
but especially the design and products used for the implants
are much improved, this means a considerable reduction in
the number of cases of capsular contraction and their
seriousness.
If necessary, he capsule can be incised in a surgical procedure
(capsulotomy).
Rupture : we have seen that implants have a limited life-span.
An implant can become porous and the silicone rubber
envelope of the implant can deteriorate. It can become
porous, have tiny leakages or split. This can be rarely after an
accident, a puncture with a needle or because of a
manufacturing flaw. Much more often, however this is due to
deterioration of the implant over time.
If the implant is filled with physiologic solution or resorbable
hydrogel the implant will deflate partially or totally, either
suddenly or slowly.
With silicone gel (non-resorbable) this will remain inside the
membrane surrounding the implant.
This can cause capsule formation or can remain un-noticed.
Rupture of the implants usually requires an operation to change
them.
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