Breast Intentions

Created on 12th January 2009

Consultant plastic surgeon, Mr James McDiarmid FRCS (Plast), reviews secondary and complex breast augmentation cases

The two essential prerequisites for a successful outcome in breast augmentation are having favourable preoperative anatomy and choosing a well qualified and experienced plastic surgeon.

What do we mean by favourable anatomy?

Well, ideally the breasts should be symmetrical and the nipple should be located on the front of the breast above the level of the inframammary fold, pointing slightly upwards and outwards. Adequate breast glandular tissue should also be present in order to ensure adequate coverage for the implant. There should be just the right amount of skin but not too much! Pregnancy, breast feeding and bodyweight fluctuations combined with the effect of gravity conspire to compromise breast aesthetics throughout life.

Case 1 shows a predictably good natural-looking result achievable when the patient is the ideal candidate for this surgery. This was achieved using an appropriately sized anatomically shaped implant in a dual plane (partially behind the pectoralis major muscle).

In my practice I use both anatomical and round implants either in front of or partially behind the muscle depending on what will work best with that individual patient’s anatomy. Sometimes the breasts may not be symmetrical, in these cases it is occasionally possible to simply insert breast implants of different sizes in order to correct the asymmetry as seen in these pictures (Case 2) although more usually the asymmetry is more marked and performing an uplift (mastopexy) on one side combined with insertion of breast implants may be the procedure of choice.

When the patient’s preoperative anatomy is not in perfect shape then greater restructuring of the breast is necessary to produce a satisfactory outcome (Case 3). This patient underwent mastopexy/augmentation to correct tubular breast deformity. Mastopexy/augmentation is the preferred option in about 10 per cent of all patients who attend my practice requesting breast augmentation – in these cases simply performing breast augmentation will almost certainly result in a double bubble deformity in patients who are prone to this as seen in this patient (Case 4) who attended my practice having had breast augmentation performed inappropriately elsewhere.

This lady had originally consulted with me but did not like the idea of mastopexy and found a surgeon who agreed to simply perform a breast augmentation instead. She returned to my practice with a double bubble deformity and this was corrected using mastopexy/augmentation with downsizing of the original implant (see the after picture) – the procedure which had originally been recommended to her.

When a patient has never undergone breast augmentation previously they are said to be having a primary breast augmentation; when the patient has already undergone breast augmentation they are said to be
a secondary case. Secondary cases (reoperations) present a far greater surgical challenge and require more detailed planning in order to achieve an optimal outcome.

Capsular contracture (implant hardening) is a frequent reason for secondary surgery and is sometimes correctable by simple capsular release (capsulotomy) or removal (capsulectomy) and implant replacement (Case 5).

If the implants have been in for a very long time it may be necessary to combine capsulotomy/-ectomy with a mastopexy as seen in Case 6
where the implants had been in place for over 20 years and the breasts had sagged as well as hardened significantly since their insertion.

Obtaining superlative outcomes with primary breast augmentation is not simply a case of inserting a silicone bag under the skin and hoping for the best. Meticulous planning can help to ensure suboptimal outcomes are avoided and that the most appropriate and safest procedure is selected for the patient on an individual basis.

Dealing with the double bubble and tubular breast deformities as well as capsular contracture presents unique challenges, few of which are insurmountable so long as the correct approach is taken.
CSMUK