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b_250_250_16777215_00_images_stories_cosmetics_brest-m.jpgBreasts have been a symbol of femininity throughout the history of humankind.  Specific aesthetic preferences can change during time and different places, but nicely shaped breasts with adequate volume will always be a sign of beauty.

Patients might want a breast augmentation for different reasons, such as feeling that her breasts have always been too small, uneven or asymmetric, wanting to regain size after lactation or losing an important amount of weight, or with abnormal breast development (i.e. Tuberous breasts) and also in cases of breast reconstruction after previous surgery.

In medical terms, breast augmentation is called augmentation mammoplasty, consists in the surgical augmentation of mammary volume through a breast implant, being one of the most common cosmetic surgical procedures to be performed along rhinoplasty and liposculpture.  In the last years the popularity of breast implants has increased, with better outcomes and patient satisfaction due to improvement in surgical techniques and implant technology to achieve the patient’s desires.

The benefits of breast augmentation, after improvement of shape and size will be related to a better self-perception, with an enhancement of the body contour, balance and proportion.  In cases of breast asymmetry and reconstructive surgery, where the emotional and psychological factor is even more important, this procedure has proven to be of great help to maintain and increase self-esteem of the patient.
In the mentioned cases we recommend breast augmentation to patients over 18 years of age, when full growth of the breast tissue is already been reached and the patient will be fully cooperative with the procedures and follow up care.


Anatomically, breasts are modified glands with the purpose of milk production for breastfeeding. Both man and women develop breast tissue from the same structures but in women they get far more developed under the influence of female sex hormones during puberty, especially estrogens.

Each breast is covered by skin and has one nipple surrounded by the areola. Under the skin a group of milk glands surrounded by fat tissue drain the milk produced during lactation period towards the nipple through lactiferous ducts. Other components of the breast glands are the connective tissue and Cooper ligaments that help to maintain their structural integrity and shape, connecting the skin to the underlying tissues. Under the breast it is located the fascia clavipectoral (a fibrous membrane that covers the pectoralis muscle).

The size and color of nipple, areola and breast size have a great variation between women and it’s influenced by genetics, age and pregnancies.
The breast gland can be subject to different pathologies, including benign lesions such as fibroadenomas, benign cysts, inflammatory processes and malignant tumors, being is important to learn breast self-examination and periodic controls with breast ultrasound or mammography depending on age and family history of breast disease.


The variety of breast implants in the market is enormous, in Arcadia Clinic are used trademarks of the highest proven quality through scientific publishing and surgical experience.
In general, breast implants of the latest generation (5th at this moment) consist in a prosthesis composed of a shell made multi-layered elastomer filled with high cohesive silicone gel. This combination made them safe and resistant against rupture and silicon migration to adjacent tissues, maintaining a more natural feel at the palpation or touch and aspect of the implant.

There are different types of implants:

Filling: An implant can be filled with sterile saline liquid (physiologic solution) or with silicone gel. Usually gel gives a more natural sensation to palpation and it’s associated to less rippling of the shell after placement, but there are some patients that require an implant filled with saline solution due to their medical antecedents and necessities.

The silicone gel can have different degrees of cohesion or thickness which changes the dynamics of the implant and at the same time makes difficult the migration of the silicone through the shell.

A third type of implant is the expandable one, with a composed filling.  In our clinic we use a new series of breast expanders for cases of breast asymmetry (where one breast is larger than the other) and breast reconstruction after mastectomy. They already contain a certain amount of high cohesive gel and a second reservoir that can be expanded with saline solution after the surgery until achieving breast symmetry and adequate volume for the surgeon and the patient. This is required when the skin envelope of the breast is too tight in the beginning, needing a slower process of expansion.

Shell type: Can be smooth or textured. The textured implants have very small micropores on their external surface, which differ a little between trademarks. The choice of implant depends more on the surgeon taste and experience. Textured implants, especially with smaller micropores, appear to show a lower rate of capsular contraction after surgery.

Natrelle Round Implants (Allergan)Textured round implants, Mentor (R)Shape: Implants can be either round or anatomic. Round implants are named because their base is round and they can rotate freely in the pocket created during the surgery without changing the shape of the breast.   Sometimes they can give a more noticeable increase in volume, specially for the upper pole. This is recommended in some patients to obtain a nicer shaping.

Anatomic breast implants (Natrelle)

Anatomical or tear-shaped implants are bigger in the lower part and usually give a more natural look of the augmented breast with fullness of the lower pole. Because they have a specific shape the placement requires the creation of a custom made surgical pocket to avoid rotation.

 

Textured anatomic implants, Mentor (R)

Each manufactured implant in the market comes with a specific serial number and certificate (implant passport) that permits the follow up of the patient through time, so patients that underwent a breast augmentation surgery should keep the card in case of need. A second copy is always saved in our files in Arcadia Clinic.

 

 

Safety

There’s been a lot of discussion in this topic and also research has been done to prove safety in long term when having breast implants. The studies show that currently there is no relationship of implants with development of breast cancer or immunological diseases. Citing The American Cancer Association, “several studies have found that breast implants do not increase breast cancer risk, although silicone breast implants can cause scar tissue to form in the breast. Implants make it harder to see breast tissue on standard mammograms, but additional x-ray pictures called implant displacement views can be used to examine the breast tissue more completely.”

An update of the Los Angeles Augmentation Mammaplasty study by Dr. D. Deapen and collaborators in a follow up of 15 years in women with Breast Implants showed no increased risk of Breast Cancer in a big study group of patients.

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A woman that is considering breast augmentation must be psychologically prepared for the change in her body shape, otherwise healthy and in good physical shape. In her first consultation with the certified plastic surgeon she must explain her wishes and expectations for the procedure and ask all the questions related to this that are in her mind. The surgeon, after considering the possibilities, physical examination and anatomical measurements will be able to discuss the best alternative for the patient related to the implant size and shape, incision placement and different details of the surgery. If required, the initial investigation will be complemented with breast ultrasound or mammography to discard any pathologic lesion and having a base image for future examinations.

Most patients wish to increase one cup size at least and during the consultation example breast implants are tried under the bra in front of a mirror to see the expected increase in volume. Usually in this stage a photographic record is taken to compare the change after the surgery and discussing with the patient other technical issues if needed. These records are kept in locked files only accessible to the treating surgeon.
The final implant selection is made according to anatomic measurements and the surgeon’s experience. Special cases of asymmetry and congenital conditions are discussed extensively with each patient, different alternatives and recommendations are tailored exclusively for every patient.

We understand the importance and sensitivity that mean for our patients a breast augmentation procedure and we give our best to achieve the maximal results in every case.

Dr. Bojan Ignatovski is a Plastic Surgeon member of the Croatian Society of Plastic and Reconstructive Surgery, with a long experience in Cosmetic Surgery. The consultation offices are located in Zagreb, Varazdin and Daruvar; and the surgical procedures are performed in Arcadia Clinic in Daruvar, Croatia.


According to the patient age and medical antecedents different tests can be taken in our clinic such as hemogram (blood analysis), coagulation, metabolic and urine tests, electrocardiogram, breast ultrasound and internal medicine evaluation when needed. If you are a young patient without clinical history of diseases only the basic tests are taken with minimal discomfort for you.
Medication such as aspirin and analgesics must be avoided 2 weeks prior the surgery and smoking suspended 3 weeks before, as both things can interfere with coagulation and oxygen delivery to the manipulated tissues. If you are taking any medication or you are allergic to any medication, material or food please notice it to the surgeon and staff people when arriving to our clinic.

Admittance to Arcadia Clinic for Plastic and Aesthetic Surgery should be arranged in advance by phone or e-mail. The patient can arrive early the same day or on the previous day of the surgery. After accommodating in the room, vital signs, tests and medical history and examination are taken, as well as anatomic measurements to confirm the choice of breast implant, and record photographs are taken if not available from before.


There are several surgical techniques for breast augmentation; currently the most popular and accepted include the placement of a breast implant made with bio-compatible materials. The implants are placed through a skin incision that can be located in different areas, such as the inframmamary fold (the skin crease under the breast), around the areola, in the axilla and even through the umbilicus. The technique of placement through each approach has different advantages and disadvantages and the choice depends in the surgeon’s recommendation as well as the patient’s characteristics, wishes and expected implant size, all of which is discussed previously during the clinical consultation with the plastic surgeon in Arcadia Clinic after the clinical examination and measurements taken.

Natrelle (R)

The mammary implant can be located directly under the gland, under the pectoralis muscle fascia or under the pectoralis muscle itself. The choice depends also in the recommendation of the surgeon, anatomic characteristics and patient’s wishes, for example, subpectoral implants (under the pectoralis muscle) tend to give a more natural look of the augmented breast; subglandular implants tend to show more increase in volume and a fuller upper pole of the breast and also are indicated in breasts that present certain degree of ptosis (with excessive skin and moderate “hanging” breasts).  You can also hear about dual plane technique, where the implant goes partially under the muscle, with a better projection of the lower pole of the breast.

Natrelle (R)


A breast augmentation surgery can be ambulatory, meaning that you can go back home the same day of the procedure, though we recommend to the patients to stay overnight to minimize any discomfort in the postoperative period, being assisted by our medicine technicians, nurses and doctors.

Once the patient is ready to start the surgery, in the room is given a mild sedative which helps to have a better and easier start of the procedure and then you are moved to the operating room.

The operation typically lasts between one and two hours under general or regional anesthesia, where the chosen breast implant is positioned and the different tissue layers are then closed, suturing the skin with intradermal technique where stitches don’t need to be removed and you don’t see them, only the incision line is noticed in the beginning (the suture material dissolves after a couple of weeks after the surgery).  A taping bandage is initially placed over the augmented breasts, which is replaced by a special elastic bra the next day.

The patient is waken up in operating room when finishing the procedure and moved to her room, where starts her recovery period. Postoperative pain generally is mild and if needed proper analgesics are given. Feeding is started few hours after and during this period the patient can be accompanied by a relative or friend in her room if wanted.
Discharge to home usually is in the next day, where all indications for care are explained and written in a discharge letter and the implant specifications (implant-passport).


 

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Breast asymmetry, pre-operative pictureBreast asymmetry, post-operative picture

 

 

 

 

 

 

 

 

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Pre-operative pictureFirst post-operative day, inframammary aproachFirst post-operative day, compressive garment


When going home everything related to the care will be written in your discharge letter.

Initially a mild massage of the breasts is recommended with round moves during showering. The purpose of this is to reduce the incidence of development of a harder capsule around the implant and should be performed in a daily basis up to 6 months. An elastic bra should be used for 2 months after the surgery, avoiding bras with metal wires for longer time. There is no need to take stitches out and the first postoperative control will be in our closest medical office to your home 7 days after the procedure.
Return to work will be possible few days after the surgery, though sports should be avoided in the first 3-4 weeks after it.   By six weeks sport activities scan be normally practiced in most cases.


The results of breast augmentation are immediately noticeable at the first dressing change in our clinic; however, it will take up to 6 weeks until the breasts take their final shape.  In most cases patients are immediately pleased with the result and go home already feeling an improvement in aspect and self-esteem.
In complex cases, like breast asymmetry and breast reconstruction using expanders, patients need some more time to get to the expected result as the dynamic changes in the breast tissue and skin envelope take more time in developing, but we warn these patients in an anticipated way that helps them to participate actively of this healing process.


Pain: There are some patients more sensitive than others to any kind of surgery, although in general the amount of pain is minor, when present it’s readily controlled with proper medication. With submuscular implants, due to the initial stretching of the muscle some patients complain of tightness that usually goes away after few days after the procedure.

Implant rupture: It’s rare nowadays since the use of last generation implants with better shells and there are several possible causes, like failure in the manipulation of the implant by inexperienced surgeons, degradation of the implant shell in older implants, chest trauma and bad technique of mammography. In case of rupture the high cohesive silicon present inside the implant prevents easy escape of it outside the shell. Signs of implant rupture can be the loss of firmness or volume in the affected breast or development of a capsular contracture. The diagnosis is suggested by clinical examination and breast ultrasound but the higher percentage of detection will be with a magnetic resonance of the breasts. The latest studies show that 5th generation implants placed by an experienced plastic surgeon have a rate of rupture of 1,1% in a follow up of 6 years. The treatment consist in removal and change of the implant.

Capsular contracture: As a natural response to the presence of an implant, the body develops a capsule around it and it's formed by collagen fibers. In few cases this reaction is more important and causes retraction of the implant, and then the breast feels more firm and can change the appearance of it.  The level of contracture is commonly classified with the Baker system from I to IV, grades III and IV requires some intervention like opening of the capsule, extirpation of the capsule and might be necessary to change the implant. To prevent this from happening we follow a strict protocol for manipulation of the implant, with use of antibiotics in the pocket for the implant and after the surgery, textured implants and prescribing massage exercises after the surgery,  all measures related to minimize the rate of contracture.

Infection: This complication is very rare because special care is taken to avoid any kind of microscopically contamination of the implant and also antibiotics are used during the surgery and few days after. Infections are reported to be treated with oral antibiotics and in case of lack of response the implant must be removed.

Hematoma and seromas: Hematomas are collections of blood and a seroma is a collection of lymphatic fluid around the implant that also can be seen in many types of surgeries in any part of the body. To prevent the formation of a closed collection we usually use very small tubes that drains any fluid present after the surgery which are removed the next day from the surgery. The removal of drains does not hurt and no extra analgesic is needed.


Congenital Breast Asymmetry: Normally, all women have some degree of difference between both breasts and this difference can be related to the volume as well as the level of nipple, areola and even the inframammary line (the skin fold under the breast). This situation is normal and does not require any treatment. When there is a clear asymmetry in the development between both breasts in the adult woman breast augmentation is a real alternative to solve this condition.
Breast asymmetry also can be part of Poland’s syndrome. Isolated, it can occur in three forms; the milder form of breast asymmetry (Type I) is considered a normal occurrence and does not require corrective surgery. The medium form of asymmetry (Type II) happens when one breast is smaller than the other by one third and cosmetic-corrective surgery is required. The severe form of breast asymmetry occurs when the difference in size exceeds 50% and when the larger breast is sagging (Type III). Poland’s Syndrome is a hereditary anomaly and it affects several organs on the same side of the body, like absence of pectoralis muscle or abnormalities of the arm, forearm and hand in the same side. In Poland’s Syndrome one breast is less developed and combined with one of the anomalies characteristic for this pathology.  The treatment of the breast abnormalities can include the placement of a breast implant and regularization of the areola and nipple trying to achieve the most symmetry as possible.

Pre-op, right breast hypoplasiaPost-op control with expandable breast implant

 

 

 

 

 

 

 

Expandable implants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tuberous Breasts: This is a condition of abnormal underdevelopment of breasts where also is observed and enlarged and puffy areola that gives the impression of having a ring around it. The cause is the presence of constrictive tissue under the skin near the areola, toward the base of the breast. Tuberous breast deformity is classified according to Von Heimburg from grades I to IV and the correction is surgical, including release of the constricted tissue in the breast, augmentation with a breast implant and reduction of the areola. For this surgery the incision approach usually is a periareolar incision.

Breast Reconstruction after Mastectomy:
There are different protocols and techniques for breast reconstruction after a surgery for breast cancer. When medical treatment is completed the patient has different options for reconstruction, in some cases it is possible the use of skin expanders to stretch the skin and after 4 to 6 months changing it for a breast implant. Cases for breast reconstruction are individually tailored to the patient’s characteristics and needs and specific program of treatment is planned.


The presence of radio-opaque breast implants may interfere with the sensitivity of screening mammography. Specialized radiographic techniques where the implant is manually displaced (Eklund views) may improve significantly.  A number of studies looking at breast cancers in women with implants have found no significant difference in stage of disease at time of diagnosis, and prognosis appears to be similar in groups with augmented patients, without a higher risk for subsequent cancer recurrence. Conversely, the use of implants for reconstruction after mastectomy for breast cancer also appears not to have a negative effect on cancer-related mortality.

An observation that patients with implants are more often diagnosed with palpable tumors (but not larger ones) suggest that tumors of equal size may be more easily palpated in augmented patients, and this may compensate somewhat for the potential impairment of mammography. This is due to thinning of the breast by compression making it easier to palpate new lesions.

The presence of a breast implant does not influence the ability for breast conservation (lumpectomy) surgery for women who develop breast cancer years after and does not interfere with delivery of radiotherapy treatments that may be required.  Fibrosis of breast tissue after radiotherapy is more common and an increase in capsular contracture rates can be expected.


Women with implants are able and encouraged to breastfeed.  Implants may cause difficulties in nursing if periareolar incisions and subglandular placement were used; thus a woman of childbearing years is advised to discuss breastfeeding with her plastic surgeon prior to surgery to choose a better approach like submuscular placement of the implant through an inframammary line incision.

A particular safety concern is whether the implant may leak into breast milk and whether this causes health problems for the nursing infant. More recent studies with more patients showed no risk for the infant, so the patient shouldn’t worry about any effect of the breast implant over the milk quality and composition.

Difficulties in breastfeeding arise if functional tissue is affected, particularly if milk ducts or major nerves were cut, or if milk glands are otherwise damaged or pressured. Duct and nerve damage is usually caused by periareolar incisions near the nipple, while other incisions (inframammary, transaxillary and transumbilical) avoid nipple tissue.  Milk glands are mostly affected by subglandular (over-the-muscle) or large implants, which cause pressure on the glands; submuscular and smaller implants cause fewer problems. However, many women have been able to successfully breastfeed with periareolar incisions and subglandular placement.

In case that you are planning to be pregnant in the near future or breastfeeding you should tell this in the initial consultation with the plastic surgeon to plan a breast augmentation technique that does not interfere with breastfeeding.


Good candidates for breast augmentation surgery are women over 18 years old with small, underdeveloped or asymmetric breasts or with breast sagging after pregnancy wanting to improve self-esteem, body shape and proportions, that are otherwise healthy and cooperative with the future procedure, being capable to follow the surgeon’s indications and necessary controls, also understanding the benefits and risks of the procedure that will be explained by the plastic surgeon.


Elastomer: An elastomer is a polymer with the property of viscoelasticity (colloquially "elasticity"). The term, which is derived from elastic polymer, is often used interchangeably with the term rubber. At ambient temperatures rubbers are thus relatively soft and deformable. Silicone rubber is generally non-reactive, stable, and resistant to extreme environments and temperatures while still maintaining its useful properties. Due to these properties and its ease of manufacturing and shaping, silicone rubber can be found in a wide variety of products like breast implants and medical devices for example.

Pectoralis Major: A muscle located in the upper chest which provides support for the breasts and is necessary for arm movements.

High cohesive silicone gel: Silicone produced in a semisolid, semiliquid state, used as a filling in breast implants, similar in consistency to a normal breast that acts more like an unit than a fluid.

Implant rippling: Rippling refers to the visible edges of a breast implant that can be seen through the skin; and sometimes felt through the skin. This usually occurs on the outer/side region of the breast and is more commonly seen in saline implants compared to silicone implants. Also, women who are especially thin with little breast tissue are more prone to the rippling or wrinkling phenomenon.

Fibroadenoma: Fibroadenomas of the breast are small, solid, rubbery, noncancerous, harmless lumps composed of fibrous and glandular tissue. Because breast cancer can also appear as a lump, doctors usually recommend a tissue sample (biopsy) to rule out cancer. Unlike typical lumps from breast cancer, fibroadenomas are easy to move, with clearly defined edges.

Breast Ultrasound: Ultrasound imaging, also called ultrasound scanning or sonography, involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound exams do not use ionizing radiation (as used in x-rays). Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels.   Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions.   Ultrasound imaging of the breast produces a picture of the internal structures of the breast.
Doppler ultrasound is a special ultrasound technique that evaluates blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs and neck.   During a breast ultrasound examination the physician performing the test may use Doppler techniques to evaluate blood flow or lack of flow in any breast mass. In some cases this may provide additional information as to the cause of the mass.

Breast Self-Examination (recommendation of The American Cancer Society): Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Women should know how their breasts normally look and feel and report any new breast changes to a health professional as soon as they are found. Finding a breast lesion does not necessarily mean that there is cancer.
A woman can notice changes by being aware of how her breasts normally look and feel and by feeling her breasts for changes (breast awareness), or by choosing to use a step-by-step approach (see below) and a specific schedule to examine her breasts.
The best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional.

Women with breast implants have do BSE also. It may be helpful to have the surgeon help identify the edges of the implant so that you know what you are feeling. There is some thinking that the implants push out the breast tissue and may actually make it easier to examine. Women who are pregnant or breast-feeding can also choose to examine their breasts regularly.


How to examine your breasts


* Lie down and place your right arm behind your head. The exam is done while lying down, not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and turn as thin as possible, making it much easier to feel all the breast tissue.
* Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.
* Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast, but you should tell your doctor if you feel anything else out of the ordinary. If you're not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast tissue before moving on to the next spot.
* Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle).   There is some evidence to suggest that the up-and-down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast, without missing any breast tissue.
* Repeat the exam on your left breast, putting your left arm behind your head and using the finger pads of your right hand to do the exam.
* While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (pressing down on the hips makes the chest wall muscles to contract enhancing any breast changes.)
* Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine.


Special Tips for Women with Breast Implants


If you have breast implants, you should perform breast self-examination monthly on your implanted breast. In order to do this effectively, you should ask your surgeon to help you distinguishing the implant from your breast tissue.
Press firmly inward at the edges of the breast implants to feel the ribs beneath, checking for any lumps or bumps. However, be careful not to manipulate (i.e., squeeze) too much the implant, specially those with anatomical shape. Any new lumps or suspicious lesions should be evaluated with a biopsy. If a biopsy is performed, care must be taken to avoid puncturing the implant.

Clinic:  Strma Ulica 16, HR - 43500 Daruvar, Hrvatska
Tel: 043 675 200     Fax: 043 675 214
Skype: poliklinika.arcadia
E-mail: poliklinika@poliklinika-arcadia.hr
Offices: Daruvar - Zagreb - Varaždin
  

 

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