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Editors

PauliinaHomsy
TiinaJahkola
CatarinaSvarvar

Breast Augmentation

Essentials

  • Breast augmentation can be done using silicone implants or fat grafting.
  • In public health care, breast augmentation is only done for developmental disorders or for acquired breast asymmetry or abnormality.
  • Any complications or long-term problems are primarily treated in the unit that placed the implants.
  • Note that this article has been written in the Finnish context and therefore the presented policies and practices may not be fully applicable in all settings. Consequently, check also local policies and practices.

Indications

  • Breast augmentation, or augmentation mammoplasty, is done in public health care for developmental breast disorders or for acquired breast asymmetry or abnormality.
    • Abnormal shape of breasts may be due to causes such as a history of chest or breast surgery, an accident or a burn.
    • Breast augmentation is done using silicone implants or the patient's own tissue, i.e. fat grafting.
  • In association with surgical treatment of breast cancer, breasts can be made more symmetrical as necessary:
    • by reducing the healthy breast by the same oncoplastic technique as used for the breast with cancer or
    • by traditional breast reduction or breast lift.
  • In public health care, the healthy breast is not augmented in association with surgery to treat cancer in the other breast.
    • For example, if in association with breast reconstruction an implant or fat is placed in the breast with cancer, the other breast is not augmented at the same time.
  • After treating cancer with radiotherapy, breast implant augmentation should be avoided due to capsular contracture, which is very common.
    • Less extensive reshaping can be done by fat grafting.
  • Augmentation of normally developed healthy breasts is only done in the private sector.

Before surgery

  • A plastic surgeon should always assess the indication and the most appropriate surgical technique individually, paying attention to the patient's wishes. Long-term consequences of surgery should be discussed.
  • When planning surgical treatment of breast asymmetry, it should always be considered whether the patient would benefit from reducing the larger breast.
  • The treatment of underlying diseases, such as diabetes or hypertension, should be optimized.
  • If the patient smokes, she should stop.
  • The skin in the breast area should be in the best possible condition.
  • Being significantly overweight is a contraindication for elective plastic surgery. A BMI of 28 or 30 is often considered the upper limit.
  • After making the decision to perform surgery, imaging of the breasts should be done by mammography, ultrasound scan, or both, depending on the patient's age and imaging findings.
    • The aim is to detect any undiagnosed breast cancer or precancerous lesion. Any further examinations required must be done before surgery.

Silicone implants

  • A silicone implant is placed either under the mammary gland, under the pectoral muscle or the upper part under the pectoral muscle and the lower part under the mammary gland.
    • The decision depends on the shape of the breast, the thickness of the tissue, and the aim.
    • The surgical scar is typically placed in the inframammary fold, sometimes at the edge of the areola or laterally close to the armpit.
  • Breast implantation is carried out under general anaesthesia, usually as day surgery.
  • After surgery, the breasts feel firm and appear lifted. This will subside as the tissues stretch.
  • The typical period of recovery is about 1 month, during which supportive garments should be worn and no physical exercise should be done.
    • Breast augmentation done in the private sector for aesthetic reasons does not entitle the patient to paid sick leave.
  • There are many types of implant varying in firmness and surface material. The choice should be made based on the target outcome. Implants are undergoing constant development.

Complications related to breast implants

  • Any complications or long-term problems are primarily treated in the unit that placed the implants.
    • If the implants were placed abroad and the patient cannot seek treatment at the same clinic, they should primarily seek assessment by a plastic surgeon in the private sector.
  • In early convalescence, a haematoma may develop around the implant, causing oedema and possibly requiring repeat surgery.
  • Serious complications associated with breast implants are relatively rare.
    • If serious inflammation develops around the implant, the implant must be removed. A new implant can only be placed after the inflammation has subsided.
  • A ruptured implant should be removed.
  • An asymptomatic, intact implant need not be changed regardless of its age or type.
  • Scar tissue called a capsule develops around all implants.
    • The capsule may sometimes thicken and harden, changing the shape of the breast, causing visible rippling of the implant or tangible hardening with unpleasant sensations and pain in the breast.
    • The need for treatment should be assessed based on the symptoms and the degree of hardening.
      • In the mildest cases, fat grafting may be considered.
      • In more severe cases, removal of the implant or the implant and the capsule will be necessary.
      • Capsular contracture may also develop around any new implant.
  • -A symptomatic breast should always be examined clinically, by mammography and/or ultrasound scan, and by core biopsy as considered necessary by the radiologist.
    • The aim is to exclude breast cancer.
    • The most accurate method of imaging breast implants is MRI.
  • An intact implant with no symptoms need not be followed up by imaging.
  • Uncomplicated breast implants do not typically affect the ability to breast feed.

Breast implant associated lymphoma

  • Breast implants may be associated with malignant changes developing around the implant possibly due to chronic inflammation.
  • Of these, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) associated with silicone implants with textured surfaces is the best known.
  • In patients with implants with textured surfaces, its incidence is estimated at 1:1 000-1:30 000.
    • The disease is so rare that removal of asymptomatic implants is not recommended.
  • Due to the risk of disease, use of implants with textured surfaces is no longer recommended.
  • The first symptom of BIA-ALCL is accumulation of fluid around the implant or a tumour associated with the implant capsule.
  • Oedema in a breast with implant should always be examined.
    • If significant fluid collection is detected around the implant, a sufficient fresh sample of the fluid should be taken under ultrasound guidance for a lymphoma pathologist to analyse.
    • Bacterial culture of the sample should be done at the same time.
    • BIA-ALCL may be seen in mammography but screening is not intended to exclude it. Clinical symptoms are more important.
  • If a doctor suspects BIA-ALCL or another malignancy, assessment by a unit specializing in cancer surgery is necessary.

Fat grafting

  • Subcutaneous fat is aspirated from a suitable part of the body and injected in thin streaks into the area to be augmented.
  • Typical aspiration sites include the abdominal wall, flanks and thighs.
  • The maximum volume of grafted fat depends on the amount of breast skin, the volume at the aspiration site and the stretchability of the tissue.
  • Not all transplanted fat attaches to the breast, and the final change achieved can be estimated about 3 months after surgery.
  • Transplantation of a volume that is high in relation to the receiving tissue increases undesirable side effects, such as oil cysts and fat necrosis seen in imaging.
    • Repeated low-volume fat grafting is better for the outcome.
  • Breast volume can be increased and the breast shape rounded by fat grafting. The breast structure will remain soft. The lifting typical with silicone implants cannot be achieved by fat grafting.
  • Fat grafting can be done under either local or general anaesthesia, in operating room conditions or in a treatment room.
    • Fat grafting is typically done as day surgery.
    • Implementation of fat grafting depends on patient-related factors, the surgeon and the procedure used in the surgical unit.
  • After surgery, the breast area should be kept warm and protected against pressure.
  • Supportive fabric should be placed on the sites of fat aspiration.
  • A few days of sick leave from office work is normally recommended.

Complications related to fat grafting

  • There will be bruising both at the site of fat aspiration and in the breasts.
  • Larger haematomas requiring treatment, and inflammation are rare.
  • The fat aspiration site is often transiently sore after surgery, and some unevenness may remain at the site.
  • Necrosis of transplanted fat may produce small or palpable oil cysts visible on an ultrasound scan and areas of calcification seen in mammography, which may subsequently lead to a need for biopsy.
  • Fat grafting has not been shown to be associated with any increased risk of first or recurrent breast cancer.
  • The operation has not been found to affect the ability to breast feed but only a few studies have been done on this.

Information to be included in the referral

  • Age, any underlying diseases, medication, allergies
  • Any history of breast surgery
  • Smoking history
  • Height, weight, BMI, distance between the jugular fossa and the nipple
  • Breast palpation finding
  • Accurate description of any problems the patient experiences from her breasts.
  • If there is an implant complication or suspected malignancy considered to require treatment in specialized care:
    • data available on the implants
    • ultrasound scan of breasts and/or mammography in primary health care

    References

    • Seth I, Bulloch G, Gibson D, et al. Autologous Fat Grafting in Breast Augmentation: A Systematic Review Highlighting the Need for Clinical Caution. Plast Reconstr Surg 2024;153(3):527e-538e [PubMed]