Introduction

Authors: Mia Demant, MD, Magnus Balslev Avnstorp, MD and Mia Steffensen, MD

This chapter covers breast augmentation with implants, which is an aesthetic procedure, that is only performed at private hospitals in Denmark. However, the insertion of implants during breast reconstruction in e.g. breast cancer patients or during transgender breast augmentation surgery (TGBA) follows the same principles and surgical considerations, which is why we have included this chapter.

Definition

Artificial enlargement of the breasts by insertion of prostheses to give the appearance of a fuller breast (increased cup size).

Indications

• Enhance the patient’s appearance if she thinks her breasts are too small or that one is smaller than the other
• Correction of congenital defects
• Adjust for a reduction in the breast size after pregnancy
• Correct uneven breasts after breast surgery for other conditions
• Improve self-confidence

Contraindications

• Smoking
• Problematic high BMI (limits may vary between each clinic)
• Age < 18 years

Pre-operative assessment

The wishes of the patient are of most importance, but these have to be put in context with the patients anatomy, including the shape of the ribcage, positioning of and differences between the breasts, grade of ptosis and tightness of the skin.

If the patient is more than 35-40 years old, she should have a mammogram done before the operation. Moreover, the patient must be informed about the possible association between breast implants and the development of breast implant-associated anaplastic large cell lymphoma (ALCL) together with other various risks, that breast augmentation poses, including:

• Capsular contraction
• Breast pain
• Infection
• Changes in the nipple size
• Breast sensation and implant leakage/rupture
• Implant rupture

Choice of incision

• Inframammary (most common)
• Periareolar
• Transaxillary
• The far less common: transumbilical or transabdominal?

Benefits and drawbacks of incision sites

	Benefits	Drawbacks
IMF incision	The best exposition of the pectoralis muscle	Thicker, slightly more visible scar
Periareolar incision	Less visible scars than IMF incision	Difficult implant emplacement due to short access-incision
Transaxillary incision	No visible scars on the breast proper	Greater risk of inferior asymmetry of the implant position

Choice of implant insertion site

Subglandular emplacement: in the retromammary space between the mammary gland and the pectoralis major muscle.

Subfascial emplacement: beneath the fascia of the pectoralis major muscle.

Subpectoral (dual plane) emplacement: beneath the pectoralis major muscle, after the surgeon releases the inferior muscular attachments, with or without partial dissection of the subglandular plane.

Submuscular emplacement: beneath the pectoralis major muscle, without releasing the inferior origin of the muscle proper.

Benefits and drawbacks of implant emplacement

	Benefits	Drawbacks
Subglandular emplacement	This usually approximates the plane of the normal breast tissue best, which affords the most aesthetic result. If the patient have small or tuberous breasts with hard breast tissue, this may expand tissue and skin to a rounder breast.	The subglandular location reduces the radiologists’ ability to interpret the mammogram because not all the breast tissue can be visualized. If the patient is very slim this method is more likely to show the ripples and wrinkles of the underlying implant. The capsular contraction rate is slightly higher. If the breast tissue is heavy, the breast may start to sag.
Submuscular emplacement	The patient’s breast tissue can be visualized and interpreted much more accurately on mammography. This achieves maximal coverage of the upper pole of the implant. It allows the expansion of the implant’s lower pole. Lower risk of breast ptosis after surgery comparing to subglandular emplacement.	High risk of animation deformities. If the patients have a high BMI and small breasts, the submuscular placement will be too deep and covered, so the implant will not appear as clearly as placing it over the muscle.

Acknowledgments

Illustrators: Caroline Lilja, med.stud.