How to Assess and Assist Patients Seeking Breast Augmentation

By Demetrius Coombs, MD, Ritwik Grover, MD, and Raffi Gurunluoglu, MD, PhD

Before breast augmentation surgery, the surgeon assesses a number of factors — physical and psychosocial — and helps the patient choose a type and size of implant. The surgeon and patient also plan where the implants will be placed — i.e., above or beneath the chest wall muscle — and where the incisions will be made. Every decision is made in close consultation with the patient, taking into account the patient’s desires and expectations, as well as what the patient’s anatomy allows. An integral component of this shared decision-making process is a discussion of the possible complications, and often photographs to better illustrate what to expect postoperatively.

Psychosocial factors

One must consider the patient’s psychology, motivations for surgery and emotional stability. Here, we look for underlying body dysmorphic disorder; excessive or unusual encouragement to undergo the procedure by a spouse, friends or others; a history of other aesthetic procedures; unrealistic expectations; and other factors influencing the desire to undergo this surgery.

Choosing an implant

Implant selection must take into account the patient’s height, weight and overall body morphology: taller patients and those with wider hips or shoulders usually require larger implants. A reliable method for determining the appropriate implant must include the current breast shape, dimensions, volume, skin elasticity, soft-tissue thickness and overall body habitus. Ultimately, the most important considerations include breast base diameter, implant volume and soft-tissue envelope.

Filler type, followed by shape (round or anatomically shaped), anterior-posterior profile and shell type (smooth or textured) are subsequent considerations. Preoperative sizing can involve placing sample implants within a brassiere so that the patient can preview possible outcomes. This method is particularly effective in minimizing dissatisfaction because it shares ownership of the decision-making process.

A computerized implant selection program available in Europe suggests a “best-fit” implant based on a clinician’s measurements.

Anatomic placement

Placement of breast implants.

Traditionally, plastic surgeons place breast implants either beneath the pectoralis major muscle (submuscular placement) or over the pectoralis but beneath the glandular breast parenchyma (subglandular placement).

Advantages of submuscular placement are a smoother transition of the upper breast pole from the chest wall and less rippling visible through the skin, due to the additional muscular coverage of the implant. Another advantage is that capsular contraction rates are lower with submuscular placement, likely due to possible contamination of implants by lactiferous ductal microbes when accessing the subglandular plane. Disadvantages are pronounced discomfort after surgery and animation deformities with muscle contraction, particularly in young, highly active patients.

The images in the top row are before breast augmentation. Those in the bottom row are seven months after breast augmentation surgery with 350-cc smooth, round silicone breast implants placed via an inframammary incision in a subpectoral pocket.

A popular modification of submuscular placement involves creating a surgical dissection plane between the subglandular tissue and the pectoralis major fascia. This “dual­­plane” approach allows the parenchyma to retract superiorly and reduce breast ptosis.

Incisions

The incision is most commonly made along the inframammary fold, but it can also be done around the areola, in the axilla or even through the umbilicus, although this approach is less commonly used.

The table below highlights important considerations with regard to incision location.

Future posts will detail potential complications of breast augmentation surgery.

Drs. Coombs and Grover are plastic surgery residents. Dr. Gurunluoglu is staff in the Department of Plastic Surgery.

This abridged article was originally published in Cleveland Clinic Journal of Medicine.