Breast augmentation

Breast augmentation
From Wikipedia, the free encyclopedia
Breast augmentation and augmentation mammoplasty are plastic surgery terms for the breast-
implant and the fat-graft mammoplasty approaches used to increase the size, change the shape, and
alter the texture of the breasts of a woman. As a primary reconstruction, augmentation
mammoplasty is applied to effect a post-mastectomy breast reconstruction, the repair of the chest
wound consequent to the removal of a cancerous breast; to correct congenital defects of the
breast(s); and to correct congenital defects of the chest wall. As an elective, cosmetic surgery,
primary augmentation changes the aesthetics -- of size, shape, and texture -- of healthy breasts.
The pre-operative aspects (left), and the post-operative aspects (right) of a bilateral, sub-muscular
emplacement of 350cc saline implants through an infra-mammary fold (IMF) incision.
The surgical implantation approach effects the global augmentation of the breast hemisphere using
a breast implant, either an implant filled with saline-solution, or an implant filled with silicone-gel;
moreover, the surgical augmentation approach can include the application of transplanted
autologous skin flaps harvested from the woman's body. The fat-graft transfer approach augments
the size and corrects contour defects of the breast hemisphere with grafts of autologous adipocyte
fat tissue, drawn from the woman's body.
In a breast-reconstruction procedure, within a multi-stage reconstruction-mammoplasty, a tissue
expander (a temporary breast-implant device) is emplaced and used to prepare (shape and enlarge)
the recipient site (implant-pocket) to receive and accommodate the breast implant prosthesis. In a
non-implant breast-augmentation procedure, some fat-graft injection approaches feature tissue-
engineering, which is the pre-operative, external expansion of the tissues of the recipient site to
receive the grafts of adipocyte tissue drawn from the woman's body. Non-surgical approaches to
breast augmentation can consist either of an externally applied vacuum-device that will expand the
tissues of the recipient site. Moreover, in most instances of fat-graft breast augmentation the
increase is of medium volume -- usually one brassière cup-size or less -- which usually is the
physiologic limit allowed by the metabolism of the woman's body.[1]
Contents
1 Surgical breast augmentation
1.1 Breast implants
1.2 Implants and breast-feeding
2 The patient
2.1 Psychology
2.2 Women bodybuilders
2.3 Mental health
3 Surgical procedures
3.1 Indications
3.2 Incision types
3.3 Implant pocket placement
3.4 Post-surgical recovery
3.5 Medical complications
3.6 Implant rupture
3.7 Capsular contracture
3.7.1 Repair and revision surgeries
3.7.2 Systemic disease and sickness
3.8 Platinum toxicity
4 Non-implant breast augmentation
4.1 Technical background
4.2 Autologous fat grafting
4.3 Fat grafting techniques
4.4 Indications
4.5 Procedures
4.6 Complications and limitations
5 Thailand Breast Slap
6 References
7 Bibliography
Surgical breast augmentation
Breast implants
For breast reconstruction, and for the augmentation and enhancement of the aesthetics -- size,
shape, and texture -- of a woman's breasts, there are three types of breast implant devices:
saline implants filled with sterile saline solution
silicone implants filled with viscous silicone gel
alternative-composition implants, filled with miscellaneous fillers -- soy oil, polypropylene string, et
cetera -- that are no longer manufactured.
Breast augmentation: saline-solution filled breast implant devices, a spherical model (left) and a
hemispheric model (right).
I. Saline breast implant
The saline breast implant -- filled with saline solution (biological-concentration salt water 0.90% w/v
of NaCl, ca. 300 mOsm/L.) -- was first manufactured by the Laboratoires Arion company, in France,
and was introduced for use as a prosthetic medical device in 1964. The contemporary models of
saline breast implant are manufactured with thicker, room-temperature vulcanized (RTV) shells
made of a silicone elastomer. The study In vitro Deflation of Pre-filled Saline Breast Implants (2006)
reported that the rates of deflation (filler leakage) of the pre-filled saline breast implant made it a
second-choice prosthesis for corrective breast surgery.[2] Nonetheless, in the 1990s, the saline
breast implant was the prosthesis usual for breast augmentation surgery, because of the U.S. FDA's
restriction against the importation of silicone-filled breast implants.
The technical goal of saline-implant technology was a physically less invasive surgical technique for
emplacing an empty breast-implant device through a smaller surgical incision.[3] In surgical praxis,
after having emplaced the empty breast implants to the implant pockets, the plastic surgeon then
filled each device with saline solution, and, because the required insertion-incisions are short and
small, the resultant incision-scars will be smaller and shorter than the surgical scars usual to the
long incisions required for inserting pre-filled, silicone-gel implants.
When compared to the results achieved with a silicone-gel breast implant, the saline implant can
yield good-to-excellent results, of increased breast-size, smoother hemisphere-contour, and realistic
texture; yet, it is likelier to cause cosmetic problems, such as the rippling and the wrinkling of the
breast-envelope skin, and technical problems, such as the presence of the implant being noticeable
to the eye and to the touch. The occurrence of such cosmetic problems is likelier in the case of the
woman with very little breast tissue, and in the case of the woman who requires post-mastectomy
breast reconstruction; thus, the silicone-gel implant is the technically superior prosthetic device for
breast augmentation, and for breast reconstruction. In the case of the woman with much breast
tissue, for whom sub-muscular emplacement is the recommended surgical approach, saline breast
implants can afford an aesthetic result much like that afforded by silicone breast implants -- a "look"
of proportionate breast size, smooth contour, and realistic texture.[4]
Breast augmentation: Late-generation models of silicone-gel breast implant devices, a spherical
model (left), a shaped model (center), and a hemispheric model (right).
II. Silicone-gel breast implant
The modern prosthetic breast was invented in 1961, by the American plastic surgeons Thomas
Cronin and Frank Gerow, and manufactured by the Dow Corning Corporation; in due course, the
first augmentation mammoplasty was performed in 1962. There are five generations of medical
device technology for the breast-implant models filled with silicone gel; each generation of breast
prosthesis is defined by common model-manufacturing techniques.
First generation
The Cronin-Gerow Implant, prosthesis model 1963, was a silicone rubber envelope-sac, shaped like a
teardrop, which was filled with viscous silicone-gel. To reduce the rotation of the emplaced breast-
implant upon the chest wall, the model 1963 prosthesis was affixed to the implant pocket with a
fastener-patch, made of Dacron material (Polyethylene terephthalate), which was attached to the
rear of the breast-implant shell.[5]
Second generation
In the 1970s, manufacturers presented the second generation of breast-implant prostheses that
featured functional developments and aesthetic improvements to the technology:
the first technological developments were a thinner-gauge device-shell, and a filler gel of low-
cohesion silicone, which improved the functionality and the verisimilitude (size, appearance, and
texture) of the silicone-gel breast implant. Yet, in clinical practice, second-generation breast
implants proved fragile, and suffered greater incidences of shell rupture, and of filler leakage
("silicone-gel bleed") through the intact device shell. The consequent, increased incidence-rates of
medical complications (e.g. capsular contracture) precipitated faulty-product, class action-lawsuits,
by the U.S. government, against the Dow Corning Corporation, and other manufacturers of breast
prostheses.
the second technological development was a polyurethane foam coating for the shell of the breast
implant; the coating reduced the incidence of capsular contracture, by causing an inflammatory
reaction that impeded the formation of a capsule of fibrous collagen tissue around the breast
implant. Nevertheless, despite that prophylactic measure, the medical use of polyurethane-coated
breast implants was briefly discontinued, because of the potential health-risk posed by 2,4-
toluenediamine (TDA), a carcinogenic by-product of the chemical breakdown of the polyurethane
foam coating of the breast implant.[6]
After reviewing the medical data, the U.S. Food and Drug Administration concluded that TDA-
induced breast cancer was an infinitesimal health-risk to women with breast implants, and did not
justify legally requiring physicians to explain the matter to their patients. In the event, polyurethane-
coated breast implants remain in plastic surgery practice in Europe and in South America; and no
manufacturer has sought FDA approval for medical sales of such breast implants in the U.S.[7]
the third technological development was the double lumen breast-implant device, a double-cavity
prosthesis composed of a silicone breast-implant contained within a saline breast-implant. The two-
fold, technical goal was: (i) the cosmetic benefits of silicone-gel (the inner lumen) enclosed in saline
solution (the outer lumen); (ii) a breast-implant device the volume of which is post-operatively
adjustable. Nevertheless, the more complex design of the double-lumen breast-implant suffered a
device-failure rate greater than that of single-lumen breast implants. The contemporary versions of
second-generation breast-implant devices (presented in 1984) are the "Becker Expandable" models
of breast implant, which are primarily used for breast reconstruction.
Third and Fourth generations
In the 1980s, the models of the Third and of the Fourth generations of breast-implant devices were
sequential advances in manufacturing technology, such as elastomer-coated shells that decreased
gel-bleed (filler leakage), and a thicker (increased-cohesion) filler gel. Sociologically, the
manufacturers of prosthetic breasts then designed and made anatomic models (natural breast) and
shaped models (round, tapered) that realistically corresponded with the breast- and body- types of
women. The tapered models of breast implant have a uniformly textured surface, which reduces the
rotation of the prosthesis within the implant pocket; the round models of breast implant are
available in smooth-surface- and textured-surface- types.
Fifth generation
Since the mid-1990s, the Fifth generation of silicone-gel breast implant is made of a semi-solid gel
that mostly eliminates the occurrences of filler leakage ("silicone-gel bleed") and of the migration of
the silicone filler from the implant-pocket to elsewhere in the woman's body. The studies Experience
with Anatomical Soft Cohesive Silicone gel Prosthesis in Cosmetic and Reconstructive Breast
Implant Surgery (2004) and Cohesive Silicone gel Breast Implants in Aesthetic and Reconstructive
Breast Surgery (2005) reported low incidence-rates of capsular contracture and of device-shell
rupture; and greater rates of improved medical-safety and technical-efficacy than that of early
generation breast-implant devices.[8][9][10]
Implants and breast-feeding
The breasts are apocrine glands that produce milk for the feeding of infant children; each breast has
a nipple within an areola (nipple-areola complex, NAC), the skin color of which varies from pink to
dark brown, and has sebaceous glands. Within the mammary gland, the lactiferous ducts produce
breast milk, and are distributed throughout the breast, with two-thirds of the tissue within 30Â mm
of the base of the nipple. In each breast, 4-18 lactiferous ducts drain to the nipple; the glands-to-fat
ratio is 2:1 in lactating women, and to 1:1 in non-lactating women; besides milk glands, the breast is
composed of connective tissue (collagen, elastin), adipose tissue (white fat), and the suspensory
Cooper's ligaments. The peripheral nervous system innervation of the breast is by the anterior and
lateral cutaneous branches of the fourth, fifth, and sixth intercostal nerves, while the thoracic spinal
nerve 4 (T4) innervating the dermatomic area supplies sensation to the nipple-areola
complex.[11][12]
Breast augmentation: cross-section scheme of the mammary gland.
1. Chest wall
2. Pectoralis muscles
3. Lobules
4. Nipple
5. Areola
6. Milk duct
7. Fatty Breast enlargement Pittsburgh tissue
8. Skin envelope
A functional breast: a mammary gland in medias res, feeding an infant child.
The functional breast
Digestive contamination and systemic toxicity are the principal infant-health concerns; the leakage
of breast implant filler to the breast milk, and if the filler is dangerous to the nursing infant. Breast
implant device fillers are biologically inert--saline filler is salt water, and silicone filler is
indigestible--because each substance is chemically inert, and environmentally common. Moreover,
proponent physicians have said there "should be no absolute contraindication to breast-feeding by
women with silicone breast implants."[13] In the early 1990s, at the beginning of the silicone breast-
implant sickness occurrences, small-scale, non-random studies (i.e. "patients came with complaints,
which might have many sources", not "doctors performed random tests") indicated possible breast-
feeding complications from silicone implants; yet no study reported device-disease causality.[14]
The augmented breast
The woman with breast implants is able to breast-feed her infant; yet breast implant devices
occasionally cause functional breast-feeding difficulties, especially the mammoplasty procedures
that feature periareolar incisions and subglandular emplacement, which have greater incidences of
breast-feeding difficulties. Therefore, to ensure her breast-feeding functionality post-surgery, the
woman of child-bearing age seeking breast implants discusses with her plastic surgeon the
implantation procedure that will least damage her lactiferous ducts and the nerves of the nipple-
areola complex (NAC).[15][16][17] Before the augmentation mammoplasty, the woman consults with
a lactation consultant, to learn what post-operative lactation and breast-feeding conditions to expect;
and consults with the plastic surgeon to jointly decide upon the implantation procedure and surgical
techniques that will least damage the breast nerves, the milk ducts, the T4 dermatomic area and the
lactiferous ducts, so that she might nurse her infant child.
Functional breast-feeding difficulties arise if the surgeon cut the milk ducts or the major nerves
innervating the breast, or if the milk glands were otherwise damaged. Milk duct and nerve damage
are more common to the periareolar incision implantation procedure, which cuts tissue near the
nipple, whereas other implantation incision-plans--IMF (inframammary fold), TABA (Trans-Axillary
Breast Augmentation), TUBA (trans-umbilical breast augmentation)--avoid the tissue of the nipple-
areola complex; if the woman is concerned about possible breast-feeding difficulties, the periareolar
incisions can be effected to reduce damage to the milk ducts and to the nerves of the NAC. The milk
glands are affected most by subglandular implants (under the gland), and by large-sized breast
implants, which pinch the lactiferous ducts and impede milk flow. Small-sized breast implants, and
submuscular implantation, cause fewer breast-function problems; however, women have successfully
breast-fed after undergoing periareolar incisions and subglandular emplacement.[17]
The patient
Further information: Body dysmorphic disorder, Body image and Beauty
Psychology
The usual breast augmentation patient is a young woman whose personality profile indicates
psychological distress about her personal appearance and her body (self image), and a history of
having endured criticism (teasing) about the aesthetics of her person.[18] The studies Body Image
Concerns of Breast Augmentation Patients (2003) and Body Dysmorphic Disorder and Cosmetic
Surgery (2006) reported that the woman who underwent breast augmentation surgery also had
undergone psychotherapy, suffered low self-esteem, presented frequent occurrences of
psychological depression, had attempted suicide, and suffered body dysmorphia--a type of mental
illness wherein she perceives non-existent physical defects. Post-operative patient surveys about the
mental health and the quality of life of the women, reported improved physical health, physical
appearance, social life, self-confidence, self-esteem, and satisfactory sexual functioning.
Furthermore, most of the women reported long-term satisfaction with their breast implants; some
despite having suffered medical complications that required surgical revision, either corrective or
aesthetic. Likewise, in Denmark, 8.0 per cent of breast augmentation patients had a pre-operative
history of psychiatric hospitalization.[19][20][21][22][23][24][25][26][27]
Women bodybuilders
Breast augmentation is an occasional recourse for women bodybuilders to retain the female figure
lost when achieving a lean and muscular physique. (professional bodybuilder Nikki Fuller)
The Cosmeticsurgery.com article They Need Bosoms, too--Women Weight Lifters (2013) reported
that women weight-lifters have resorted to breast augmentation surgery to maintain a feminine
physique, and so compensate for the loss of breast mass consequent to the increased lean-body mass
and decreased body-fat consequent to lifting weights.[28]
Mental health
The longitudinal study Excess Mortality from Suicide and other External Causes of Death Among
Women with Cosmetic Breast Implants (2007), reported that women who sought breast implants are
almost 3.0 times as likely to commit suicide as are women who have not sought breast implants.
Compared to the standard suicide-rate for women of the general populace, the suicide-rate for
women with augmented breasts remained alike until 10-years post-implantation, yet it increased to
4.5 times greater at the 11-year mark, and so remained until the 19-year mark, when it increased to
6.0 times greater at 20-years post-implantation. Moreover, additional to the suicide-risk, women with
breast implants also faced a trebled death risk from alcoholism and drugs abuse (prescription and
recreational).[29][30] Although seven studies have statistically connected a woman's undergoing a
breast augmentation procedure to a greater suicide-rate, the research indicates that augmenation
surgery does not increase the suicide death-rate; and that, in the first instance, it is the
psychopathologically-inclined woman who is likelier to undergo breast
augmentation.[31][32][33][34][35][36]
Moreover, the study Effect of Breast Augmentation Mammoplasty on Self-Esteem and Sexuality: A
Quantitative Analysis (2007), reported that the women attributed their improved self-esteem, self-
image, and increased, satisfactory sexual functioning to having undergone breast augmentation; the
cohort, aged 21-57 years, averaged post-operative self-esteem increases ranging from 20.7 to 24.9
points on the 30-point Rosenberg self-esteem scale, which data supported the 78.6 per cent increase
in the woman's libido, relative to her pre-operative level of libido. Therefore, before agreeing to any
surgical procedure, the plastic surgeon evaluates and considers the woman's mental health to
determine if breast implants can positively affect her self-esteem and sexual functioning.[37]
Surgical procedures
Indications
Breast augmentation: The post-operative aspect of a right-breast cancer mastectomy; the woman is a
candidate for a primary breast reconstruction with a breast implant.
An augmenation mammoplasty for emplacing breast implants has three therapeutic purposes:
primary reconstruction: to replace breast tissues damaged by trauma (blunt, penetrating, blast),
disease (breast cancer), and failed anatomic development (tuberous breast deformity).
revision and reconstruction: to revise (correct) the outcome of a previous breast reconstruction
surgery.
primary augmentation: to aesthetically augment the size, form, and feel of the breasts.
The operating room time of post-mastectomy breast reconstruction, and of breast augmentation
surgery is determined by the emplacement procedure employed, the type of incisional technique, the
breast implant (type and materials), and the pectoral locale of the implant pocket.[38]
Incision types
The emplacement of a breast implant device is performed with five types of surgical incisions:[39]
Inframammary: an incision made below the breast, in the infra-mammary fold (IMF), which affords
maximal access for precise dissection and emplacement of the breast implant devices. It is the
preferred surgical technique for emplacing silicone-gel implants, because of the longer incisions
required; yet, IMF implantation can produce thicker, slightly more visible surgical scars.
Periareolar: an incision made along the areolar periphery (border), which provides an optimal
approach when adjustments to the IMF position are required, or when a mastopexy (breast lift) is
included to the primary mammoplasty procedure. In the periareolar emplacement method, the
incision is around the medial-half (inferior half) of the areola's circumference. Silicone-gel implants
can be difficult to emplace with this incision, because of the short, five-centimetre length (~
5.0Â cm.) of the required access-incision. Aesthetically, because the scars are at the areola's border,
they usually are less visible than the IMF-incision scars of women with light-pigment areolae.
Furthermore, periareolar implantation produces a greater incidence of capsular contracture, severs
the milk ducts and the nerves to the nipple, thus causes the most post-operative functional problems,
e.g. impeded breast feeding.
Transaxillary: an incision made to the axilla (armpit), from which the dissection tunnels medially,
thus allows emplacing the implants without producing visible scars upon the breast proper; yet is
likelier to produce inferior asymmetry of the implant-device position. Therefore, surgical revision of
transaxillary emplaced breast implants usually requires either an IMF incision or a periareolar
incision. Transaxillary emplacement can be performed bluntly or with an endoscope (illuminated
video microcamera).
Transumbilical: a trans-umbilical breast augmentation (TUBA) is a less common implant-device
insertion technique wherein the incision is at the navel, and the dissection tunnels superiorly. This
surgical approach enables emplacing the breast implants without producing visible scars upon the
breast; but it makes appropriate dissection and device-emplacement more technically difficult. A
TUBA procedure is performed bluntly--without the endoscope's visual assistance--and is not
appropriate for emplacing (pre-filled) silicone-gel implants, because of the great potential for
damaging the elastomer silicone shell of the breast-implant device during its manual insertion
through the short--two-centimetre (~2.0Â cm.)--incision at the navel, and because pre-filled silicone-
gel implants are incompressible, and cannot be inserted through so small an incision.[40]
Transabdominal--as in the TUBA procedure, in the transabdominoplasty breast augmentation
(TABA), the breast implants are tunneled superiorly from the abdominal incision into bluntly
dissected implant pockets, whilst the patient simultaneously undergoes an abdominoplasty.[41]
Implant pocket placement
The four (4) surgical approaches to emplacing a breast implant to the implant pocket are described
in anatomical relation to the pectoralis major muscle.
Subglandular -- the breast implant is emplaced to the retromammary space, between the breast
tissue (the mammary gland) and the pectoralis major muscle (major muscle of the chest), which most
approximates the plane of normal breast tissue, and affords the most aesthetic results. Yet, in
women with thin pectoral soft-tissue, the subglandular position is likelier to show the ripples and
wrinkles of the underlying implant. Moreover, the capsular contracture incidence rate is slightly
greater with subglandular implantation.
Subfascial -- the breast implant is emplaced beneath the fascia of the pectoralis major muscle; the
subfascial position is a variant of the subglandular position for the breast implant.[42] The technical
advantages of the subfascial implant-pocket technique are debated; proponent surgeons report that
the layer of fascial tissue provides greater implant coverage and better sustains its position.[43]
Subpectoral (dual plane) -- the breast implant is emplaced beneath the pectoralis major muscle, after
the surgeon releases the inferior muscular attachments, with or without partial dissection of the
subglandular plane. Resultantly, the upper pole of the implant is partially beneath the pectoralis
major muscle, while the lower pole of the implant is in the subglandular plane. This implantation
technique achieves maximal coverage of the upper pole of the implant, whilst allowing the expansion
of the implant's lower pole; however, "animation deformity", the movement of the implants in the
subpectoral plane can be excessive for some patients.[44]
Submuscular -- the breast implant is emplaced beneath the pectoralis major muscle, without
releasing the inferior origin of the muscle proper. Total muscular coverage of the implant can be
achieved by releasing the lateral muscles of the chest wall -- either the serratus muscle or the
pectoralis minor muscle, or both -- and suturing it, or them, to the pectoralis major muscle. In breast
reconstruction surgery, the submuscular implantation approach effects maximal coverage of the
breast implants.
Post-surgical recovery
The surgical scars of a breast augmentation mammoplasty heal at 6-weeks post-operative, and fade
within several months, according to the skin type of the woman. Depending upon the daily physical
activity the woman might require, the augmentation mammoplasty patient usually resumes her
normal life activities at about 1-week post-operative. The woman who underwent submuscular
implantation (beneath the pectoralis major muscles) usually has a longer post-operative
convalescence, and experiences more pain, because of the healing of the deep-tissue cuts into the
chest muscles for the breast augmenation. The patient usually does not exercise or engage in
strenuous physical activities for about 6 weeks. Moreover, during the initial convalescence, the
patient is encouraged to regularly exercise (flex and move) her arms to alleviate pain and
discomfort; and, as required, analgesic medication catheters for alleviating pain.[45][46]
Medical complications
The plastic surgical emplacement of breast-implant devices, either for breast reconstruction or for
aesthetic purpose, presents the same health risks common to surgery, such as adverse reaction to
anesthesia, hematoma (post-operative bleeding), seroma (fluid accumulation), incision-site
breakdown (wound infection). Complications specific to breast augmentation include breast pain,
altered sensation, impeded breast-feeding function, visible wrinkling, asymmetry, thinning of the
breast tissue, and symmastia, the "bread loafing" of the bust that interrupts the natural plane
between the breasts. Specific treatments for the complications of indwelling breast implants-
-capsular contracture and capsular rupture--are periodic MRI monitoring and physical examinations.
Furthermore, complications and re-operations related to the implantation surgery, and to tissue
expanders (implant place-holders during surgery) can cause unfavorable scarring in approximately
6-7% of the patients. [26][47][48]Statistically, 20% of women who underwent cosmetic implantation,
and 50% of women who underwent breast reconstruction implantation, required their explantation
at the 10-year mark.[49]
Implant rupture
Because a breast implant is a Class III medical device of limited product-life, the principal rupture-
rate factors are its age and design; Nonetheless, a breast implant device can retain its mechanical
integrity for decades in a woman's body.[50] When a saline breast implant ruptures, leaks, and
empties, it quickly deflates, and thus can be readily explanted (surgically removed). The follow-up
report, Natrelle Saline-filled Breast Implants: a Prospective 10-year Study (2009) indicated rupture-
deflation rates of 3-5 per cent at 3-years post-implantation, and 7-10 per cent rupture-deflation rates
at 10-years post-implantation.[51]
Breast-implant failure: The parts of a surgically explanted breast-implant are the red, fibrous capsule
(left), the ruptured silicone implant (center), and the transparent filler-gel that leaked to the
woman's pectoral tissues (right).
When a silicone breast implant ruptures it usually does not deflate, yet the filler gel does leak from
it, which can migrate to the implant pocket; therefore, an intracapsular rupture (in-capsule leak) can
become an extracapsular rupture (out-of-capsule leak), and each occurrence is resolved by
explantation. Although the leaked silicone filler-gel can migrate from the chest tissues to elsewhere
in the woman's body, most clinical complications are limited to the breast and armpit areas, usually
manifested as granulomas (inflammatory nodules) and axillary lymphadenopathy (enlarged lymph
glands in the armpit area).[52][53][54]
The suspected mechanisms of breast-implant rupture are
damage during implantation
damage during (other) surgical procedures
chemical degradation of the breast implant shell
trauma (blunt trauma, penetrating trauma, blast trauma)
mechanical pressure of traditional mammographic breast examination [55]
Silicone implant rupture can be evaluated using magnetic resonance imaging; from the long-term
MRI data for single-lumen breast implants, the European literature about second generation
silicone-gel breast implants (1970s design), reported silent device-rupture rates of 8-15 per cent at
10-years post-implantation (15-30% of the patients).[56][57][58][59]
The study Safety and Effectiveness of Mentor's MemoryGel Implants at 6 Years (2009), which was a
branch study of the U.S. FDA's core clinical trials for primary breast augmentation surgery patients,
reported low device-rupture rates of 1.1 per cent at 6-years post-implantation.[60] The first series of
MRI evaluations of the silicone breast implants with thick filler-gel reported a device-rupture rate of
1.0 per cent, or less, at the median 6-year device-age.[61] Statistically, the manual examination
(palpation) of the woman is inadequate for accurately evaluating if a breast implant has ruptured.
The study, The Diagnosis of Silicone Breast-implant Rupture: Clinical Findings Compared with
Findings at Magnetic Resonance Imaging (2005), reported that, in asymptomatic patients, only 30
per cent of the of ruptured breast implants is accurately palpated and detected by an experienced
plastic surgeon, whereas MRI examinations accurately detected 86 per cent of breast-implant
ruptures.[62] Therefore, the U.S. FDA recommended scheduled MRI examinations, as silent-rupture
screenings, beginning at the 3-year-mark post-implantation, and then every two years,
thereafter.[26] Nonetheless, beyond the U.S., the medical establishments of other nations have not
endorsed routine MRI screening, and, in its stead, proposed that such a radiologic examination be
reserved for two purposes: (i) for the woman with a suspected breast-implant rupture; and (ii) for
the confirmation of mammographic and ultrasonic studies that indicate the presence of a ruptured
breast implant.[63]
Furthermore, The Effect of Study design Biases on the Diagnostic Accuracy of Magnetic Resonance
Imaging for Detecting Silicone Breast Implant Ruptures: a Meta-analysis (2011) reported that the
breast-screening MRIs of asymptomatic women might overestimate the incidence of breast-implant
rupture.[64] In the event, the U.S. Food and Drug Administration emphasised that "breast implants
are not lifetime devices. The longer a woman has silicone gel-filled breast implants, the more likely
she is to experience complications."[65]
Capsular contracture
Main article: Capsular contracture
The human body's immune response to a surgically installed foreign object -- breast implant, cardiac
pacemaker, orthopedic prosthesis -- is to encapsulate it with scar tissue capsules of tightly woven
collagen fibers, in order to maintain the integrity of the body by isolating the foreign object, and so
tolerate its presence. Capsular contracture -- which should be distinguished from normal capsular
tissue -- occurs when the collagen-fiber capsule thickens and compresses the breast implant; it is a
painful complication that might distort either the breast implant, or the breast, or both.
Breast-implant failure: Capsular contracture is a medical complication, in this case, a Baker scale
Grade IV contraction, of a subglandular silicone implant in the right breast.
The cause of capsular contracture is unknown, but the common incidence factors include bacterial
contamination, device-shell rupture, filler leakage, and hematoma. The surgical implantation
procedures that have reduced the incidence of capsular contracture include submuscular
emplacement, the use of breast implants with a textured surface (polyurethane-coated);[66][67][68]
limited pre-operative handling of the implants, limited contact with the chest skin of the implant
pocket before the emplacement of the breast implant, and irrigation of the recipient site with triple-
antibiotic solutions.[69][70]
The correction of capsular contracture might require an open capsulotomy (surgical release) of the
collagen-fiber capsule, or the removal, and possible replacement, of the breast implant.
Furthermore, in treating capsular contracture, the closed capsulotomy (disruption via external
manipulation) once was a common maneuver for treating hard capsules, but now is a discouraged
technique, because it can rupture the breast implant. Non-surgical treatments for collagen-fiber
capsules include massage, external ultrasonic therapy, leukotriene pathway inhibitors such as
zafirlukast (Accolate) or montelukast (Singulair), and pulsed electromagnetic field therapy
(PEMFT).[71][72][73][74]
Repair and revision surgeries
When the woman is unsatisfied with the outcome of the augmentation mammoplasty; or when
technical or medical complications occur; or because of the breast implants' limited product life
(Class III medical device, in the U.S.), it is likely she might require replacing the breast implants.
The common revision surgery indications include major and minor medical complications, capsular
contracture, shell rupture, and device deflation.[55] Revision incidence rates were greater for breast
reconstruction patients, because of the post-mastectomy changes to the soft-tissues and to the skin
envelope of the breast, and to the anatomical borders of the breast, especially in women who
received adjuvant external radiation therapy.[55] Moreover, besides breast reconstruction, breast
cancer patients usually undergo revision surgery of the nipple-areola complex (NAC), and symmetry
procedures upon the opposite breast, to create a bust of natural appearance, size, form, and feel.
Carefully matching the type and size of the breast implants to the patient's pectoral soft-tissue
characteristics reduces the incidence of revision surgery. Appropriate tissue matching, implant
selection, and proper implantation technique, the re-operation rate was 3.0% at the 7-year-mark,
compared with the re-operation rate of 20% at the 3-year-mark, as reported by the U.S. Food and
Drug Administration.[75][76]
Systemic disease and sickness
Since the 1990s, reviews of the studies that sought causal links between silicone-gel breast implants
and systemic disease reported no link between the implants and subsequent systemic and
autoimmune diseases.[63][77][78][79] Nonetheless, during the 1990s, thousands of women claimed
sicknesses they believed were caused by their breast implants, including neurological and
rheumatological health problems.
Breast Implant: the chest X-ray of a woman with bilaterally emplaced breast implants shows that the
prostheses are radiographically opaque, and are foreign objects in her body, but not of her body.
In the study Long-term Health Status of Danish Women with Silicone Breast Implants (2004), the
national healthcare system of Denmark reported that women with implants did not risk a greater
incidence and diagnosis of autoimmune disease, when compared to same-age women in the general
population; that the incidence of musculoskeletal disease was lower among women with breast
implants than among women who had undergone other types of cosmetic surgery; and that they had
a lower incidence rate than like women in the general population.[80][81]
Follow-up longitudinal studies of these breast implant patients confirmed the previous findings on
the matter.[82] European and North American studies reported that women who underwent
augmentation mammoplasty, and any plastic surgery procedure, tended to be healthier and
wealthier than the general population, before and after implantation; that plastic surgery patients
had a lower standardized mortality ratio than did patients for other surgeries; yet faced an increased
risk of death by lung cancer than other plastic surgery patients. Moreover, because only one study,
the Swedish Long-term Cancer Risk Among Swedish Women with Cosmetic Breast Implants: an
Update of a Nationwide Study (2006), controlled for tobacco smoking information, the data were
insufficient to establish verifiable statistical differences between smokers and non-smokers that
might contribute to the higher lung cancer mortality rate of women with breast implants.[83][84]
The long-term study of 25,000 women, Mortality among Canadian Women with Cosmetic Breast
Implants (2006), reported that the "findings suggest that breast implants do not directly increase
mortality in women."[34]
The study Silicone gel Breast Implant Rupture, Extracapsular Silicone, and Health Status in a
Population of Women (2001), reported increased incidences of fibromyalgia among women who
suffered extracapsular silicone-gel leakage than among women whose breast implants neither
ruptured nor leaked.[85] The study later was criticized as significantly methodologically flawed, and
a number of large subsequent follow-up studies have not shown any evidence of a causal device-
disease association. After investigating, the U.S. FDA has concluded "the weight of the
epidemiological evidence published in the literature does not support an association between
fibromyalgia and breast implants.".[86][87] The systemic review study, Silicone Breast implants and
Connective tissue Disease: No Association (2011) reported the investigational conclusion that "any
claims that remain regarding an association between cosmetic breast implants and CTDs are not
supported by the scientific literature".[88]
Platinum toxicity
The manufacture of silicone breast implants requires the metallic element Platinum (Pt., 78) as a
catalyst to accelerate the transformation of silicone oil into silicone gel for making the elastomer
silicone shells, and for making other medical-silicone devices.[89] The literature indicates that trace
quantities of platinum leak from such types of silicone breast implant; therefore, platinum is present
in the surrounding pectoral tissue(s). The rare pathogenic consequence is an accumulation of
platinum in the bone marrow, from where blood cells might deliver it to nerve endings, thus causing
nervous system disorders such as blindness, deafness, and nervous tics (involuntary muscle
contractions).[89]
Breast-implant: The metallic element Platinum (Pt., 78) a catalyst in the manufacture of silicone
breast implants, was a suspected cause of toxic contamination (tissue ionization) in the bodies of
women with such implants.
In 2002, the U.S. Food and Drug Administration (U.S. FDA) reviewed the studies on the human
biological effects of breast-implant platinum, and reported little causal evidence of platinum toxicity
to women with breast implants.[90] Furthermore, in the journal "Analytical Chemistry", the study
Total Platinum Concentration and Platinum Oxidation States in Body Fluids, Tissue, and Explants
from Women Exposed to Silicone and Saline Breast Implants by IC-ICPMS (2006), proved
controversial for claiming to have identified previously undocumented toxic platinum oxidative
states in vivo.[91] Later, in a letter to the readers, the editors of the "Analytical Chemistry" journal
published their concerns about the faulty experimental design of the study, and warned readers to
"use caution in evaluating the conclusions drawn in the paper."[92]
Furthermore, after reviewing the research data of the study Total Platinum Concentration and
Platinum Oxidation States in Body Fluids, Tissue, and Explants from Women Exposed to Silicone and
Saline Breast Implants by IC-ICPMS, and other pertinent literature, the U.S. FDA reported that the
data do not support the findings presented; that the platinum used, in new-model breast-implant
devices, likely is not ionized, and therefore is not a significant risk to the health of the women.[93]
Non-implant breast augmentation
Technical background
Liposuction
The technique of liposuction (lipoplasty) was conceived and developed by the Italian plastic surgeons
Arpat Fischer and Giorgio Fischer in 1974, and was put into medico-clinical practice in 1975.[94]
Access to the woman's autologous adipocyte fat was by means of 5-mm incisions, and was harvested
with an electrically and pneumatically -powered instrument, which rotated and alternated in its
aspiration of the fat through a cannula. Meanwhile, through a separate incision to the fat-tissue
harvest site, saline solution was injected to dilute the body fat, and so facilitate its aspiration.[95]
In 1977, Fisher and Fischer reviewed 245 cases with the planotome instrument for treating cellulite
in the lateral trochanteric (hip-thigh) areas. There was a 4.9 per cent incidence of seromas, despite
incision-wound suction catheters and compression dressings; 2.0 per cent of the cases presented
pseudo-cyst formation that required removal of the capsule (cyst) through a wider incision (+
5.0Â mm) and the use of the panotome.[96][97]
The advent of liposuction technology facilitated medical applications of the liposuction-harvested fat
tissue as autologous filler for injection to correct bodily defects, and for breast augmentation. Melvin
Bircoll introduced the practice of contouring the breast and for correcting bodily defects with
autologous fat grafts harvested by liposuction; and he presented the fat-injection method used for
emplacing the fat grafts.[98][99] In 1987 the Venezuelan plastic surgeon Eduardo Krulig emplaced
fat grafts with a syringe and blunt needle (lipo-injection), and later used a disposable fat trap to
facilitate the collection and to ensure the sterility of the harvested adipocyte tissue.[100][101]
Lipo-injector gun
To emplace the grafts of autologous fat-tissue, doctors J. Newman and J. Levin designed a lipo-
injector gun with a gear-driven plunger, which allowed the even injection of autologous fat-tissue to
the desired recipient sites. The control afforded by the lipo-injector gun assisted the plastic surgeon
in controlling excessive pressure to the fat in the barrel of the syringe, thus avoiding over-filling the
recipient site.[102] The later-design lipo-injector gun featured a ratchet-gear operation that afforded
the surgeon greater control in accurately emplacing grafts of autologous fat to the recipient site; a
trigger action injected 0.1Â cm3 of filler.[103] Since 1989, most non-surgical, fat-graft augmentation
of the breast features the emplacement of adipocyte fat outside the breast parenchyma -- up to 300
ml of fat -- in three equal measures (aliquots), is emplaced to the subpectoral space and to the
intrapectoral space of the pectoralis major muscle, and the submammary space, to achieve a breast
outcome of natural appearance and contour.[104]
Autologous fat grafting
The technique of autologous fat-graft injection to the breast is applied for the correction of breast
asymmetry; of breast deformities; for post-mastectomy breast reconstruction (as a primary and as an
adjunct technique); for the improvement of soft-tissue coverage of breast implants; and for the
aesthetic enhancement of the bust. The careful harvesting and centrifugal refinement of the mature
adipocyte tissue (injected in small aliquots) allows the transplanted fat tissue to remain viable in the
breast, where it provides the anatomical structure and the hemispheric contour that cannot be
achieved solely with breast implants or with corrective plastic surgery.
Non-implant breast augmenation: the pre-procedural aspects (left) and the post-procedural aspects
(right) of breasts enlarged and contoured with autologous fat grafts.
In fat-graft breast augmentation procedures, there is the risk that the adipocyte tissue grafted to the
breast(s) can undergo necrosis, metastatic calcification, develop cysts, and agglomerate into
palpable lumps. Although the cause of metastatic calcification is unknown, the post-procedure
biological changes occurred to the fat-graft tissue resemble the tissue changes usual to breast
surgery procedures such as reduction mammoplasty. The French study Radiological Evaluation of
Breasts Reconstructed with Lipo-modeling (2005) indicates the therapeutic efficacy of fat-graft
breast reconstruction in the treatment of radiation therapy damage to the chest, the incidental
reduction of capsular contracture, and the improved soft-tissue coverage of breast
implants.[105][106][107][108][109][110]
The study Fat Grafting to the Breast Revisited: Safety and Efficacy (2007) reported successful
transferences of body fat to the breast, and proposed the fat-graft injection technique as an
alternative (non-implant) augmentation mammoplasty procedure instead of the surgical procedures
usual for effecting breast augmentation, breast-defect correction, and breast reconstruction.
In a 17-patient cohort, two women had breast cancer (diagnosed by mammogram) one at 12-months
post-procedure, and the other at 92-months post-procedure. In contemporary surgical praxis, to
realize the required correction, aside from the breast proper, fat grafts are injected to the pectoralis
major muscle, to the postpectoral space and to the prepectoral space, before and behind said
muscle. In post-mastectomy breast reconstruction, the grafted fat is used to create a breast mound,
by augmenting the extant breast tissues that remained after the surgical removal of the cancerous
breast. Structural fat-grafting was performed either to one breast or to both breasts of the 17
women; the age range of the women was 25-55 years, and the mean age was 38.2 years. The women
of the study cohort presented clinical indications such as micromastia (10 patients); explantation
deformity (one patient); post-augmentation deformity, with breast implants (two patients); tuberous
breast deformity (one patient); Poland's syndrome (one patient); and post-mastectomy
reconstruction deformity (two patients).
The pre-procedure mammograms were negative for malignant neoplasms. The types of anaesthesia
applied were general (two patients) and epidural analgesia plus sedation, with local infiltration and
intercostal nerve blocks (15 patients). The autologous adipocyte tissue was grafted in one-to-three
stages; the average volume of a tissue-graft was 278.6Â cm3 of fat per operation, per breast. Post-
procedure, each patient was instructed to regard any lump in the breasts as unrelated to the fat
grafts, until after breast cosmetic surgery Pittsburgh a complete medical workup of the breast lump
had been performed.[111] Moreover, the study Cell-assisted Lipotransfer for Cosmetic Breast
Augmentation: Supportive Use of Adipose-Derived Stem/Stromal Cells (2007), about a 40-woman
cohort, indicated that the inclusion of adipose stem cells to the grafts of adipocyte fat increased the
rate of corrective success of the autologous fat-grafting procedure.[112]
Fat grafting techniques
Fat harvesting and contouring
The centrifugal refinement of the liposuction-harvested adipocyte tissues removes blood products
and free lipids to produce autologous breast filler. The injectable filler-fat is obtained by centrifuging
(spinning) the fat-filled syringes for sufficient time to allow the serum, blood, and oil (liquid fat)
components to collect, by density, apart from the refined, injection-quality fat.[113] To refine the fat
for facial injection quality, the fat-filled syringes are centrifuged for 1.0 minute at 2,000 RPM, which
separates the unnecessary solution, leaving refined filler-fat.[114] Moreover, centrifugation at
10,000 RPM for 10 minutes produces a "collagen graft"; the histologic composition of which is cell
residues, collagen fibres, and 5.0 per cent intact fat cells. Furthermore, because the patient's body
naturally absorbs some of the fat grafts, the breasts maintain their contours and volumes for 18-24
months.[115][116]
Fat-graft breast augmentation: the pre-operative aspects (left) and the post-operative aspects (right)
of a large-volume non-surgical augmentation.
In the study Fat Grafting to the Breast Revisited: Safety and Efficacy (2007), the investigators
reported that the autologous fat was harvested by liposuction, using a 10-ml syringe attached to a
two-hole Coleman harvesting cannula; after centrifugation, the refined breast-filler fat was
transferred to 3-ml syringes. Blunt infiltration cannulas were used to emplace the fat through 2-mm
incisions; the blunt cannula injection method allowed greater dispersion of small aliquots (equal
measures) of fat, and reduced the possibility of intravascular fat injection; no sharp needles are used
for fat-graft injection to the breasts. The 2-mm incisions were positioned to allow the infiltration
(emplacement) of fat grafts from at least two directions; a 0.2 ml fat volume was emplaced with each
withdrawal of the cannula.[117]
The breasts were contoured by layering the fat grafts into different levels within the breast, until
achieving the desired breast form. The fat-graft injection technique allows the plastic surgeon
precise control in accurately contouring the breast--from the chest wall to the breast-skin envelope-
-with subcutaneous fat grafts to the superficial planes of the breast. This greater degree of breast
sculpting is unlike the global augmentation realised with a breast implant emplaced below the
breast or below the pectoralis major muscle, respectively expanding the retromammary space and
the retropectoral space. The greatest proportion of the grafted fat usually is infiltrated to the
pectoralis major muscle, then to the retropectoral space, and to the prepectoral space, (before and
behind the pectoralis major muscle). Moreover, although fat grafting to the breast parenchyma
usually is minimal, it is performed to increase the degree of projection of the bust.[111]
Fat-graft injection
The biologic survival of autologous fat tissue depends upon the correct handling of the fat graft, of
its careful washing (refinement) to remove extraneous blood cells, and of the controlled, blunt-
cannula injection (emplacement) of the refined fat-tissue grafts to an adequately vascularized
recipient site. Because the body resorbs some of the injected fat grafts (volume loss), compensative
over-filling aids in obtaining a satisfactory breast outcome for the patient; thus the transplantation of
large-volume fat grafts greater than required, because only 25-50 per cent of the fat graft survives at
1-year post-transplantation.[118]
The correct technique maximizes fat graft survival by minimizing cellular trauma during the
liposuction harvesting and the centrifugal refinement, and by injecting the fat in small aliquots
(equal measures), not clumps (too-large measures). Injecting minimal-volume aliquots with each
pass of the cannula maximizes the surface area contact, between the grafted fat-tissue and the
recipient breast-tissue, because proximity to a vascular system (blood supply) encourages histologic
survival and minimizes the potential for fat necrosis.[111] Transplanted autologous fat tissue
undergoes histologic changes like those undergone by a bone transplant; if the body accepts the fat-
tissue graft, it is replaced with new fat tissue, if the fat-graft dies it is replaced by fibrous tissue.
New fat tissue is generated by the activity of a large, wandering histocyte-type cell, which ingests fat
and then becomes a fat cell.[119] When the breast-filler fat is injected to the breasts in clumps (too-
large measures), fat cells emplaced too distant from blood vessels might die, which can lead to fat
tissue necrosis, causing lumps, calcifications, and the eventual formation of liponecrotic cysts.
Fat-graft breast augmentation: the pre-operative aspects (left) and the post-operative aspects (right)
of a medium-volume non-surgical augmentation.
The operating room (OR) time required to harvest, refine, and emplace fat to the breasts is greater
than the usual 2-hour OR time; the usual infiltration time was approximately 2-hours for the first
100Â cm3 volume, and approximately 45 minutes for injecting each additional 100Â cm3 volume of
breast-filler fat. The technique for injecting fat grafts for breast augmentation allows the plastic
surgeon great control in sculpting the breasts to the required contour, especially in the correction of
tuberous breast deformity. In which case, no fat-graft is emplaced beneath the nipple-areola complex
(NAC), and the skin envelope of the breast is selectively expanded (contoured) with subcutaneously
emplaced body-fat, immediately beneath the skin. Such controlled contouring selectively increased
the proportional volume of the breast in relation to the size of the nipple-areola complex, and thus
created a breast of natural form and appearance; greater verisimilitude than is achieved solely with
breast implants. The fat-corrected, breast-implant deformities, were inadequate soft-tissue coverage
of the implant(s) and capsular contracture, achieved with subcutaneous fat-grafts that hid the
implant-device edges and wrinkles, and decreased the palpability of the underlying breast implant.
Furthermore, grafting autologous fat around the breast implant can result in softening the breast
capsule.[120]
External tissue expansion
The successful outcome of fat-graft breast augmentation is enhanced by achieving a pre-expanded
recipient site to create the breast-tissue matrix that will receive grafts of autologous adipocyte fat.
The recipient site is expanded with an external vacuum tissue-expander applied upon each breast.
The biological effect of negative pressure (vacuum) expansion upon soft tissues derives from the
ability of soft tissues to grow when subjected to controlled, distractive, mechanical forces. (see
distraction osteogenesis) The study Non-surgical Breast Enlargement using an External Soft Tissue
Expansion System (2000) reported the technical effectiveness of recipient-site pre-expansion. In a
single-group study, 17 healthy women (aged 18-40 years) wore a brassiere-like vacuum system that
applied a 20-mmHg vacuum (controlled, mechanical, distraction force) to each breast for 10-12
hours daily for 10-weeks. Pre- and post-procedure, the breast volume (size) was periodically
measured; likewise, a magnetic resonance image (MRI) of the breast-tissue architecture and water
density was taken during the same phase of the patient's menstrual cycle; of the 17-woman study
group, 12 completed the study, and 5 withdrew, because of non-compliance with the clinical trial
protocol.[121]
The breast volume (size) of all 17 women increased throughout the 10-week treatment period, the
greatest increment was at week 10 (final treatment)--the average volume increase was 98+/-67 per
cent over the initial breast-size measures. Incidences of partial recoil occurred at 1-week post-
procedure, with no further, significant, breast volume decrease afterwards, nor at the follow-up
treatment at 30-weeks post-procedure. The stable, long-term increase in breast size was 55 per cent
(range 15-115%). The MRI visualizations of the breasts showed no edema, and confirmed the
proportionate enlargement of the adipose and glandular components of the breast-tissue matrices.
Furthermore, a statistically significant decrease in body weight occurred during the study, and self-
esteem questionnaire scores improved from the initial-measure scores.[121]
Because external vacuum expansion of the recipient-site tissues permits injecting large-volume fat
grafts (+300cc) to correct defects and enhance the bust, the histologic viability of the breast filler
(adipocyte fat) and its volume must be monitored and maintained. The long-term, volume
maintenance data reported in Breast Augmentation using Pre-expansion and Autologous Fat
Transplantation: a Clinical Radiological Study (2010) indicate the technical effectiveness of external
tissue expansion of the recipient site for a 25-patient study group, who had 46 breasts augmented
with fat grafts. The indications included micromastia (underdevelopment), explantation deformity
(empty implant pocket), and congenital defects (tuberous breast deformity, Poland's
syndrome).[122]
Pre-procedure, every patient used external vacuum expansion of the recipient-site tissues to create a
breast-tissue matrix to be injected with autologous fat grafts of adipocyte tissue, refined via low G-
force centrifugation. Pre- and post-procedure, the breast volumes were measured; the patients
underwent pre-procedure and 6-month post-procedure MRI and 3-D volumetric imaging
examinations. At 6-months post-procedure, each woman had a significant increase in breast volume,
ranging 60-200 per cent, per the MRI (n=12) examinations. The size, form, and feel of the breasts
was natural; post-procedure MRI examinations revealed no oil cysts or abnormality (neoplasm) in
the fat-augmented breasts. Moreover, given the sensitive, biologic nature of breast tissue, periodic
MRI and 3-D volumetric imaging examinations are required to monitor the breast-tissue viability and
the maintenance of the large volume (+ 300cc) fat grafts.[122]
Indications
Non-implant breast augmentation with injections of autologous fat grafts (adipocyte tissue) is
indicated for women requiring breast reconstruction, defect correction, and the æsthetic
enhancement of the bust.
breast reconstruction: post-mastectomy re-creation of the breast(s); trauma-damaged tissues (blunt,
penetrating), disease (breast cancer), and explantation deformity (empty breast-implant socket).
congenital defect correction": micromastia, tuberous breast deformity, Poland's syndrome, et cetera.
primary augmentation: the aesthetic enhancement (contouring) of the size, form, and feel of the
breasts.
The operating room (OR) time of breast reconstruction, congenital defect correction, and primary
breast augmentation procedures is determined by the indications to be treated.
Procedures
Post-mastectomy surgical reconstruction
Surgical post-mastectomy breast reconstruction requires general anaesthesia, cuts the chest
muscles, produces new scars, and requires a long post-surgical recovery for the patient. The surgical
emplacement of breast implant devices (saline or silicone) introduces a foreign object to the
patient's body (see capsular contracture). The TRAM flap (Transverse Rectus Abdominis
Myocutaneous flap) procedure reconstructs the breast using an autologous flap of abdominal,
cutaneous, and muscle tissues. The latissimus myocutaneous flap employs skin fat and muscle
harvested from the back, and a breast implant. The DIEP flap (Deep Inferior Epigastric Perforators)
procedure uses an autologous flap of abdominal skin and fat tissue.[123]
Post-mastectomy fat graft reconstruction
The reconstruction of the breast(s) with grafts of autologous fat is a non-implant alternative to
further surgery after a breast cancer surgery, be it a lumpectomy or a breast removal--simple (total)
mastectomy, radical mastectomy, modified radical mastectomy, skin-sparing mastectomy, and
subcutaneous (nipple-sparing) mastectomy. The breast is reconstructed by first applying external
tissue expansion to the recipient-site tissues (adipose, glandular) to create a breast-tissue matrix
that can be injected with autologous fat grafts (adipocyte tissue); the reconstructed breast has a
natural form, look, and feel, and is generally sensate throughout and in the nipple-areola complex
(NAC).[123] The reconstruction of breasts with fat grafts requires a three-month treatment period-
-begun after 3-5 weeks of external vacuum expansion of the recipient-site tissues. The autologous
breast-filler fat is harvested by liposuction from the patient's body (buttocks, thighs, abdomen), is
refined and then is injected (grafted) to the breast-tissue matrices (recipient sites), where the fat will
thrive.
One method of non-implant breast reconstruction is initiated at the concluding steps of the breast
cancer surgery, wherein the oncological surgeon is joined by the reconstructive plastic surgeon, who
immediately begins harvesting, refining, and seeding (injecting) fat grafts to the post-mastectomy
recipient site. After that initial post-mastectomy fat-graft seeding in the operating room, the patient
leaves hospital with a slight breast mound that has been seeded to become the foundation tissue
matrix for the breast reconstruction. Then, after 3-5 weeks of continual external vacuum expansion
of the breast mound (seeded recipient-site)--to promote the histologic regeneration of the extant
tissues (fat, glandular) via increased blood circulation to the mastectomy scar (suture site)--the
patient formally undergoes the first fat-grafting session for the reconstruction of her breasts. The
external vacuum expansion of the breast mound created an adequate, vascularised, breast-tissue
matrix to which the autologous fat is injected; and, per the patient, such reconstruction affords
almost-normal sensation throughout the breast and the nipple-areola complex. Patient recovery from
non-surgical fat graft breast reconstruction permits her to resume normal life activities at 3-days
post-procedure.[123]
Tissue engineering
I. the breast mound
The breast-tissue matrix consists of engineered tissues of complex, implanted, biocompatible
scaffolds seeded with the appropriate cells. The in-situ creation of a tissue matrix in the breast
mound is begun with the external vacuum expansion of the mastectomy defect tissues (recipient
site), for subsequent seeding (injecting) with autologous fat grafts of adipocyte tissue. A 2010 study
reported that serial fat-grafting to a pre-expanded recipient site achieved (with a few 2-mm incisions
and minimally invasive blunt-cannula injection procedures), a non-implant outcome equivalent to a
surgical breast reconstrcution by autologous-flap procedure. Technically, the external vacuum
expansion of the recipient-site tissues created a skin envelope as it stretched the mastectomy scar,
and so generated a fertile breast-tissue matrix to which were injected large-volume fat grafts (150-
600 ml) to create a breast of natural form, look, and feel.[124]
The fat graft breast reconstructions for 33 women (47 breasts, 14 irradiated), whose clinical statuses
ranged from zero days to 30 years post-mastectomy, began with the pre-expansion of the breast
mound (recipient site) with an external vacuum tissue-expander for 10 hours daily, for 10-30 days
before the first grafting of autologous fat. The breast mound expansion was adequate when the
mastectomy scar tissues stretched to create a 200-300 ml recipient matrix (skin envelope), that
received a fat-suspension volume of 150-600 ml in each grafting session.[124]
At one week post-procedure, the patients resumed using the external vacuum tissue-expander for 10
hours daily, until the next fat grafting session; 2-5 outpatient procedures, 6-16 weeks apart, were
required until the plastic surgeon and the patient were satisfied with the volume, form, and feel of
the reconstructed breasts. The follow-up mammogram and MRI examinations found neither defects
(necrosis) nor abnormalities (neoplasms). At six months post-procedure, the reconstructed breasts
had a natural form, look, and feel, and the stable breast-volumes ranged 300-600 ml per breast. The
post-procedure mammographies indicated normal, fatty breasts with well-vascularized fat, and few,
scattered, benign oil cysts. The occurred complications included pneumothorax and transient
cysts.[124]
II. Explantation deformity
The autologous fat graft replacement of breast implants (saline and silicone) resolves medical
complications such as: capsular contracture, implant shell rupture, filler leakage (silent rupture),
device deflation, and silicone-induced granulomas, which are medical conditions usually requiring
re-operation and explantation (breast implant removal). The patient then has the option of surgical
or non-implant breast corrections, either replacement of the explanted breast implants or fat-graft
breast augmentation. Moreover, because fat grafts are biologically sensitive, they cannot survive in
the empty implantation pocket, instead, they are injected to and diffused within the breast-tissue
matrix (recipient site), replacing approximately 50% of the volume of the removed implant--as
permanent breast augmentation. The outcome of the explantation correction is a bust of natural
appearance; breasts of volume, form, and feel, that--although approximately 50% smaller than the
explanted breast size--are larger than the original breast size, pre-procedure.[125]
III. Breast augmentation
The outcome of a breast augmentation with fat-graft injections depends upon proper patient
selection, preparation, and correct technique for recipient site expansion, and the harvesting,
refining, and injecting of the autologous breast-filler fat. Technical success follows the adequate
external vacuum expansion of the recipient-site tissues (matrix) before the injection of large-volume
grafts (220-650 cc) of autologous fat to the breasts. After harvesting by liposuction, the breast-filler
fat was obtained by low G-force syringe centrifugation of the harvested fat to separate it, by density,
from the crystalloid component. The refined breast filler then was injected to the pre-expanded
recipient site; post-procedure, the patient resumed continual vacuum expansion therapy upon the
injected breast, until the next fat grafting session. The mean operating room (OR) time was 2-hours,
and there occurred no incidences of infection, cysts, seroma, hematoma, or tissue necrosis.[122]
The breast-volume data reported in Breast Augmentation with Autologous Fat Grafting: A Clinical
Radiological Study (2010) indicated a mean increase of 1.2 times the initial breast volume, at six
months post-procedure. In a two-year period, 25 patients underwent breast augmentation by fat
graft injection; at three weeks pre-procedure, before the fat grafting to the breast-tissue matrix
(recipient site), the patients were photographed, and examined via intravenous contrast MRI or 3-D
volumetric imaging, or both. The breast-filler fat was harvested by liposuction (abdomen, buttocks,
thighs), and yielded fat-graft volumes of 220-650Â cm3 per breast. At sex months post-procedure,
the follow-up treatment included photographs, intravenous contrast MRI or 3-D volumetric imaging,
or both. Each woman had an increased breast volume of 250Â cm3 per breast, a mean volume
increase confirmed by quantitative MRI analysis. The mean increase in breast volume was 1.2 times
the initial breast volume measurements; the statistical difference between the pre-procedure and the
six-month post-procedure breast volumes was (P< 00.0000007); the percentage increase basis of the
breast volume was 60-80% of the initial, pre-procedure breast volume.[122]
Complications and limitations
Medical complications
In every surgical and non-surgical procedure, the risk of medical complications exists before, during,
and after a procedure, and, given the sensitive biological nature of breast tissues (adipocyte,
glandular), this is especially true in the case of fat graft breast augmentation. Despite its relative
technical simplicity, the injection (grafting) technique for breast augmentation is accompanied by
post-procedure complications--fat necrosis, calcification, and sclerotic nodules--which directly
influence the technical efficacy of the procedure, and of achieving a successful outcome. The
Chinese study Breast Augmentation by Autologous Fat-injection Grafting: Management and Clinical
analysis of Complications (2009), reported that the incidence of medical complications is reduced
with strict control of the injection-rate (cm3/min) of the breast-filler volume being administered, and
by diffusing the fat-grafts in layers to allow their even distribution within the breast tissue matrix.
The complications occurred to the 17-patient group were identified and located with 3-D volumetric
and MRI visualizations of the breast tissues and of any sclerotic lesions and abnormal tissue masses
(malignant neoplasm). According to the characteristics of the defect or abnormality, the sclerotic
lesion was excised and liquefied fat was aspirated; the excised samples indicated biological changes
in the intramammary fat grafts--fat necrosis, calcification, hyalinization, and fibroplasia.[126]
The complications associated with injecting fat grafts to augment the breasts are like, but less
severe, than the medical complications associated with other types of breast procedure. Technically,
the use of minuscule (2-mm) incisions and blunt-cannula injection much reduce the incidence of
damaging the underlying breast structures (milk ducts, blood vessels, nerves). Injected fat-tissue
grafts that are not perfused among the tissues can die, and result in necrotic cysts and eventual
calcifications--medical complications common to breast procedures. Nevertheless, a contoured
abdomen for the patient is an additional benefit derived from the liposuction harvesting of the
adipocyte tissue injected to the breasts. (see abdominoplasty)
Technical limitations
When the patient's body has insufficient adipocyte tissue to harvest as injectable breast filler, a
combination of fat grafting and breast implants might provide the desired outcome. Although non-
surgical breast augmentation with fat graft injections is not associated with implant-related medical
complications (filler leakage, deflation, visibility, palpability, capsular contracture), the achievable
breast volumes are physically limited; the large-volume, global bust augmentations realised with
breast implants are not possible with the method of structural fat grafting. Global breast
augmentation contrasts with the controlled breast augmentation of fat-graft injection, in the degree
of control that the plastic surgeon has in achieving the desired breast contour and volume. The
controlled augmentation is realised by infiltrating and diffusing the fat grafts throughout the breast;
and it is feather-layered into the adjacent pectoral areas until achieving the desired outcome of
breast volume and contour. Nonetheless, the physical fullness-of-breast achieved with injected fat-
grafts does not visually translate into the type of buxom fullness achieved with breast implants;
hence, patients who had plentiful fat-tissue to harvest attained a maximum breast augmentation of
one brassi?re cup-size in one session of fat grafting to the breast.[111]
Breast cancer
Detection
A contemporary woman's life-time probability of developing breast cancer is approximately one in
seven;[127] yet there is no causal evidence that fat grafting to the breast might be more conducive
to breast cancer than are other breast procedures; because incidences of fat tissue necrosis and
calcification occur in every such procedure: breast biopsy, implantation, radiation therapy, breast
reduction, breast reconstruction, and liposuction of the breast. Nonetheless, detecting breast cancer
is primary, and calcification incidence is secondary; thus, the patient is counselled to learn self-
palpation of the breast and to undergo periodic mammographic examinations. Although the
mammogram is the superior diagnostic technique for distinguishing among cancerous and benign
lesions to the breast, any questionable lesion can be visualized ultrasonically and magnetically
(MRI); biopsy follows any clinically suspicious lesion or indeterminate abnormality appeared in a
radiograph.[111]
Therapy
Breast augmentation via autologous fat grafts allows the oncological breast surgeon to consider
conservative breast surgery procedures that usually are precluded by the presence of alloplastic
breast implants, e.g. lumpectomy, if cancer is detected in an implant-augmented breast. In
previously augmented patients, aesthetic outcomes cannot be ensured without removing the implant
and performing mastectomy.[128][129] Moreover, radiotherapy treatment is critical to reducing
cancerous recurrence and to the maximal conservation of breast tissue; yet, ironically, radiotherapy
of an implant-augmented breast much increases the incidence of medical complications--capsular
contracture, infection, extrusion, and poor cosmetic outcome.[111]
Post-cancer breast reconstruction
After mastectomy, surgical breast reconstruction with autogenous skin flaps and with breast
implants can produce subtle deformities and deficiencies resultant from such global breast
augmentation, thus the breast reconstruction is incomplete. In which case, fat graft injection can
provide the missing coverage and fullness, and might relax the breast capsule. The fat can be
injected as either large grafts or as small grafts, as required to correct difficult axillary deficiencies,
improper breast contour, visible implant edges, capsular contracture, and tissue damage consequent
to radiation therapy.[111]
Thailand Breast Slap
The Thailand Breast Slap is a non-surgical method of breast augmentation endorsed by the Thai
government as an alternative to surgical breast augmentation with breast implants. The Thai
government enrolled more than 20 women in publicly funded courses for the teaching of the
technique; nonetheless, beyond Thailand, the technique is not endorsed by the mainstream medical
community. Despite the promising results of a six-month study of the therapeutic effectiveness of the
technique, the research physician recommended to the participant women that they also contribute
to augmenting their busts by gaining weight.[130]
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Bibliography
Schiffman MA (2010). Autologous Fat Transfer: Art, Science, and Clinical Practice. Berlin,
Heidelberg: Springer. ISBNÂ 3642004725.
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