Breast augmentation
The operation
The next stage is coming in for surgery. I will see you immediately before the operation which is another chance for you to ask any questions. I will then mark the incision site and key landmarks, with you awake and standing.
Surgery is usually performed under general anaesthesia and most people stay in hospital overnight following the operation. I usually leave a small drain in the wound which is removed before you leave hospital. The wounds are closed with absorbable sutures which are left buried under your skin and in the deeper tissues and therefore there are no sutures to remove. Steristrips or suture tapes are also used. A band of tape is placed across the upper and lower parts of the breast at surgery which should remain in place for a week to stabilise the implants. A bra that you have used for sizing can be worn over these dressings on discharge from hospital and we will usually see you again a week later when all dressings will be removed.
Access incisions
There are three types of incisions in use;
Infra-mammary fold
Axillary
Peri-areolar
My preferred incision is beneath the breast in the future infra-mammary fold. The incision is actually made below your present infra-mammary fold as skin is drawn up onto the breast by the implant. The infra-mammary fold incision gives the best access to the space that we need to create for the implant. The infra-mammary fold incision allows the implant to be placed in any of the layers or planes that we may want to position it in. It also allows careful control of bleeding and accurate placement of the implant.
The axillary incision is underneath the arm. When using this incision the implant can only be placed under the muscle. The space to accept the implant is created by feel rather than direct vision and involves tearing of tissues with increased damage to them.
The incision around the nipple (peri-areolar) finds less favour with patients in Northern Europe and North America. If you have a large areolar, access can be as good as when using the inframammary incision, but there is an increased risk of damaging feeling to the nipple and of infection with contamination from the glandular and ductal system of the breast.
Placement of the implant
An implant is not an exact replica of the breast. The natural breast thins out towards it edge with a margin which is often difficult to define or feel. An implant has a much more obvious edge to it and this edge needs to be disguised by the body's tissues to prevent it from being seen and/or felt. Many patients will be familiar with images of people who have breast implants where the outline of the implant can be clearly seen in the upper part of the breast. With appropriate placement and selection of the implant this can be avoided.
In most people there is enough tissue in the upper part of the breast which is either subcutaneous fat or breast tissue to disguise the upper part of the implant when the implant is in the subglandular or submammary plane. However if you are very thin we may need another layer of tissue to disguise the implant and we then use the muscle on the chest wall called the pectoralis major. The implant is then in the submuscular or subpectoral plane.
The implant can be placed in one of several layers;
- underneath the breast only - subglandular plane
- underneath the muscle - subpectoral plane
- underneath the breast in its lower half and muscle in the upper half of the breast - dual plane
- underneath the breast and the covering layer of tissue on the muscle known as the fascia - subfascial plane.
Another disadvantage of placement underneath the muscle is that the muscle may become attached to the implant with excessive movement of the implant with arm and shoulder movement. To minimise this effect yet still gain the advantages of a subpectoral placement the dual plane technique is now used where muscle cover is required. In this technique we place the lower part of the implant underneath breast tissue only which maximises the projection achieved and then the upper part of the implant is placed under the muscle to disguise the implant. This method detaches muscle from the breast tissue reducing the incidence of unwanted mobility but maintaining the advantages of submuscular plane placement.
Occasionally in favourable circumstances we may do a subfascial placement. This raises a thinner layer of tissue from the surface of the muscle to help smooth the contour of the implant but does not disturb the muscle itself.
Determining which plane to place the implant in is decided by your physique, choice of implants, and your wishes. This will of course be discussed with you before surgery. The firmer implant, particularly if it is anatomically shaped, will need more disguise than a soft round implant and therefore is more likely to be placed underneath muscle rather than the breast only.
