Silicone breast implant augmentation is a clinically mature and safe breast augmentation procedure, and it is also the most dominant and common breast augmentation procedure at present. Recently, the Chinese Society of Plastic Surgery promulgated the Clinical Technical Guidelines for Silicone Breast Implant Breast Augmentation in order to better promote the development of the plastic surgery industry, the details of which are as follows.
Silicone breast implant augmentation is a clinically mature and safe way of breast augmentation surgery, and it is also the main and most common way of breast augmentation surgery at present. In order to enable breast augmentation patients in China to obtain more aesthetic, lasting and safe surgical results and good long-term quality of life, and to reduce complications and reoperation rates of silicone breast implant augmentation surgery, there is an urgent need to establish a set of standard, optimized and systematic technical guidelines. Based on a large amount of literature at home and abroad, we summarize the basic principles of successful breast augmentation surgery and put forward concise and practical recommendations, with a view to guiding plastic surgeons to better perform breast augmentation surgery independently and promoting the development and overall improvement of breast augmentation technology in China.
I. Patient selection
Careful selection of suitable patients is essential to obtain long-term, satisfactory postoperative results. Although the indications for breast implant augmentation are very broad, not every patient who comes to the clinic is suitable for the surgery. In principle, patients undergoing breast augmentation should be at least 18 years old, and breastfeeding patients should have stopped breastfeeding for at least six months. Patients who are clearly suffering from some kind of mental illness or have significant psychiatric abnormalities are not suitable for breast augmentation surgery. It must also be clearly understood that implants can increase breast volume but cannot solve the problems of breast asymmetry, nipple flare or (and) asymmetry, and wide cleavage, which can hardly be completely solved by implant breast augmentation surgery alone.
Second, patient education and informed consent
Patient education is essential to obtain satisfactory postoperative results of breast augmentation. Plastic surgeons should provide patients with comprehensive and detailed information about breast augmentation, including implants, incisions, risks, recovery process, and long-term situation. Professional guidance is also given to patients to help them choose the appropriate implants and to give them reasonable expectations of the postoperative results.
Patient education is a phased and repetitive process. Compared to the surgical operation and the application of the prosthesis itself, patient education has a greater impact on patient satisfaction with the surgical outcome. Good patient education, detailed informed consent, and the content of related counseling help to reconcile the fallout between one’s own tissue conditions and expectations, and are essential to achieving patient satisfaction. Patients must be made aware that there are no breasts that are perfectly symmetrical on both sides, and that there is no thermal warming or surgical method that can make both breasts perfectly symmetrical. The fully expected surgical effect of breast augmentation is an increase in breast volume. Breast augmentation is not a repositioning of the breast position, nor can it flush the position of the nipple, nor can it accurately predict the shape, position and feel of the postoperative breast before surgery.
Pre-operative preparation
1.Medical history taking It is necessary to ask the patient carefully about the reason for consultation, and detailed medical history information can help to understand whether the patient’s physical and mental conditions are suitable for breast augmentation surgery.
2.Related examinations The necessary physical examination and related auxiliary examinations should be carried out, mainly including the following: blood and urine routine, bleeding and coagulation functions, liver and kidney functions, hepatitis virus index, HIV, RPR, blood sugar test, electrocardiogram, chest X-ray, etc. The patient should have received breast examination in breast surgery within 1 year before the operation, and the occupying breast lesion should be excluded.
Pre-operative measurement and photography should be performed in the patient’s standing position, and the measurement data should be recorded in the case. Pre-operative photography should include 5 standard positions: frontal, left (right) oblique, left (right) lateral, and other positions if necessary. The photographic area should include the neck, umbilicus, and both arms. The measurement data should contain at least the following: sternotomy – nipple distance (S-N)
Nipple – median distance (N-M)
Breast basal width (BW, parasternal – anterior axillary line distance measured when the breast is small PS-AA)
Nipple – inferior inframammary fold distance (N-IMF, measured at maximal traction)
Transcatheter Nipple Chest Circumference (CC-N)
Transcatheter inframammary fold circumference (CC-IMF)
Squeeze thickness of subcutaneous tissue at the upper pole of the breast (STPTUP)
Subcutaneous tissue pinch thickness of the lower breast crease (STPTIMF)
Fourth, the choice of breast implants
1.No manufacturer guarantees that the implant will be placed in the body for life, and the same doctor cannot make a commitment to the patient to place it for life.
2.There is no institution that has any regulations on the duration of silicone breast implants placed in the body, and there is no recommendation that they must be removed within a certain period of time.
3, according to the U.S. FDA released “silicone breast implant safety assessment report” of the relevant data, there is no data to show that silicone breast implants and known human diseases have a direct relationship, a large number of investigation data show: silicone breast implants will not increase the risk of breast tumors, will not affect fertility and breastfeeding, is a safe and reliable breast implant materials.
4, the softness of silicone breast implants does not have a direct correspondence with the feel of the breast after surgery. Under the same conditions, high polymer silicone gel-filled breast implants will feel slightly harder, but the integrity of the gel makes it more difficult to leak, and once ruptured it is easier to remove completely.
5, some studies have concluded that the use of hairy surface implants can reduce the incidence of postoperative contracture and better maintain the long-term stability of the shape and position of the implant, a conclusion that still needs to be supported by longer-term clinical data.
6, the use of anatomical implants can make the lower pole of the breast fuller and the upper pole of the breast more natural, and help to maintain the long-term stability of the breast shape, more suitable for loose skin and mildly sagging breasts.
7.The purpose of breast augmentation surgery is not only to increase the volume of the breast, but also to shape the natural beauty and long-term stability of the breast shape. Therefore, it is necessary to select the type and parameters of the implant according to each patient’s body characteristics and measurement size, rather than simply considering the volume only. The shape and size of the implant as well as the patient’s own tissue characteristics and original breast volume should be taken into account when selecting an implant. The distance between the parasternal line and the anterior axillary line is the main constraint in determining the bottom transverse diameter of the prosthesis, and in most cases, the bottom transverse diameter of the prosthesis selected should be less than this distance. If the patient requires an implant size that is beyond the permissible range of physical conditions, the risks must be explained to the patient.
Although increasing the volume of the implant is likely to improve patient satisfaction, the plastic surgeon must make the patient clearly understand that the larger the volume of the implant, the greater the risk of breast augmentation, the incidence of complications such as nipple areola sensory disturbances, palpable implants, surface rippling, and the potential for increased long-term complication rates.
V. Incisional Approach
At present, there are usually three types of incisional approaches for silicone breast implant placement: axillary incision, areolar incision, and inframammary fold incision, and they have different advantages and disadvantages. Breast augmentation needs to consider not only the concealment of the incision scar, but also the complications and recovery process associated with the chosen incision. Plastic surgeons should be familiar with the advantages, disadvantages and technical points of various incisions, and choose the most appropriate incision according to their own experience, patients’ requirements and their own conditions.
2.The axillary incision is the most frequently chosen incision in domestic clinical practice. Its biggest advantage is that its location is relatively hidden, but compared with the inframammary fold and areola incision, it is more difficult to precisely peel off the prosthesis cavity under blind vision through the axillary incision, and it is difficult to precisely control the accuracy and symmetry of the prosthesis location, and the risk of postoperative complications is relatively higher.
3. Endoscopic-assisted transaxillary approach breast augmentation technology can change blind vision into direct vision, achieve precise peeling and effective hemostasis, thus helping to reduce the risk of complications. When conditions and technology are available, the application of endoscopic assistance in transaxillary incision breast augmentation technique is a better choice, but this technique depends on expensive equipment, requires high technical requirements for the surgeon, and requires special training and certain experience.
4.Transcatheter inframammary fold incision for breast augmentation is the most convenient procedure. This procedure has short access and peeling off of the implant cavity and hemostasis can be performed under direct vision, but the incision is located on the front of the breast, and if the patient’s desired breast volume is not large, it may not be possible to hide the incision marks. Patients should be reminded to consider carefully when they have a tendency to scar growth and have concerns about scarring in the breast area.
5. The areolar incision also allows the surgeon to perform precise luminal stripping and hemostatic operations under direct vision, and in most cases the scarring of the areolar incision is not obvious, but this approach generally requires incision of the breast tissue, which may increase the risk of nipple areolar sensory disturbance and breastfeeding disorders. In addition, patients with an areola diameter of less than 3.5 cm and less elastic areola skin are not suitable for this incision.
6. When a revision surgery or implant removal is needed again, it can be performed through the original inframammary fold incision and areolar incision without additional incision scarring. In most cases, patients who use the axillary incision for the first time usually need to choose a new incision when operating again.
6. Levels of implant placement
1. The levels of implant placement include post-mammary, post-pectoral fascia, post-pectoralis major, and biplanar. The level of implant placement depends on the tissue coverage on the surface of the implant, the thinner the tissue coverage, the deeper the implant should be placed, and studies have shown that postoperative complications may be less after the implant is placed behind the pectoralis major muscle or biplanar than after the breast is placed.
2, in the case of thin subcutaneous soft tissue thickness around the breast, should avoid placing the prosthesis in the post-mammary level to avoid problems such as palpable prosthesis and too obvious prosthesis contour. In the case of weight loss, old and thin, etc., the prosthesis placed behind the breast is more likely to produce more problems.
3, the use of dual-plane technology can reduce the compression of the pectoralis major muscle on the prosthesis, reduce the tendency of the prosthesis to move up after surgery, and make the lower pole of the breast more full. When the STPTIMF is less than 1cm, the pectoralis major muscle should be avoided at the level of the new lower crease, and the muscle should be separated at the level of at least 1cm above the original lower crease to ensure good tissue coverage of the prosthesis here.
VII. Surgical operation
1.It is recommended to complete the breast augmentation surgery under general anesthesia.
2. Strict aseptic operation is ensured throughout the surgery to reduce the risk of infection and contracture of the envelope. It is recommended to apply a patch to cover the nipple area during surgery (regardless of which incisional approach is chosen) and to avoid contact with extraneous objects as much as possible. Intraoperative re-prosthesis and/or implantation cavity with antibiotics is recommended and the operator should change sterile, powder-free gloves prior to contact with the prosthesis. It is not recommended to apply disinfectant solution to soak the prosthesis.
3.It is not recommended to use too small an incision to place the prosthesis in order not to affect the morphology and integrity of the prosthesis.
4.It should be peeled under direct vision as much as possible to form a suitable cavity for prosthesis placement to obtain better surgical results.
5. It is recommended to place negative pressure drainage according to the intraoperative situation.
VIII. Postoperative care
1. It is recommended to stay in the hospital for at least 24h for postoperative observation and to give analgesic drugs to relieve pain. Prevent the application of antibiotics during the perioperative period.
2.Patients should be fully degraded with possible conditions during the postoperative recovery period, such as temporary nipple overflow, upper limb strips with difficulty in movement and pain, etc. At the same time, postoperative precautions should be fully explained, such as diet, body position, upper limb activities, avoiding hot compresses, etc.
3.Massage is not recommended after the placement of hairy surface prosthesis.
4.If the axillary incision approach is used, it is recommended that the upper pole of the breast be compressed with an elastic restraint band for 3 weeks after surgery, while upper limb activities should be appropriately restricted.
5.It is recommended to take preventive treatment measures, including the use of anti-scar dressings and preparations to prevent scar proliferation, reduce pigmentation and improve the appearance of the scar.
6.If drainage is placed, daily drainage flow and color of each side should be observed and recorded, and aseptic operation should be strictly performed when pouring drainage fluid or changing drainage containers, and the drainage tube can generally be removed after the drainage flow is less than 40 ml/d per side.
7. Accurate and detailed medical records of the patient should be kept. Basic information about the prosthesis and surgery should be kept in the medical record and information cards should be provided to the patient, including information about the type of implanted prosthesis, the quality certificate of the prosthesis, the incision and the level of implantation of the prosthesis.
8.Improve the long-term follow-up system after breast augmentation surgery, and take all possible measures to follow up patients after surgery, which will help improve the breast augmentation surgery technique. Patients should be encouraged to review regularly, and the early follow-up time is recommended to be 1 month, 3 months, 6 months, 1 year after surgery. 1 year after the follow-up time varies from case to case, with a general interval of about 2 years.
9. It is the responsibility of the plastic surgeon to collect and report post-augmentation follow-up information, including adverse events, complications, etc.
Nine, complications
1, possible complications of breast implant augmentation surgery include but are not limited to: infection, hematoma, seroma, pain, thrombophlebitis (Monder’s disease), delayed healing of the incision, incision scar growth, skin pigmentation loss or hyperpigmentation near the incision, incision extension or additional incision, nipple areola sensory disturbance or abnormality, unsatisfactory or asymmetric breast morphology size, implant displacement or ectasia, exposed implant, the implant transposition (anatomical implant), implant wrinkling or rippling, palpable implant, implant leakage or rupture, implant envelope contracture, etc.
2, about envelope contracture: It is agreed that the cause of envelope contracture is still unclear, and individual differences in the body’s reaction to the foreign body of the prosthesis are still the intrinsic determinants of the difference in postoperative breast feel and the occurrence of envelope contracture. In addition, it has been suggested that the occurrence of peri-implant contracture may be related to the presence of bacteria, hematoma, foreign bodies, trauma, leaking implants, and other causative factors. Plastic surgeons cannot predict and prevent the occurrence of periosteal contracture, but they should continuously improve their surgical techniques and do their best to reduce the influence of the above-mentioned predisposing factors.
X. Technical progress
Research on breast augmentation technology and prosthesis is still developing and advancing, and plastic surgeons should continue to learn and understand the latest technological advances and master the latest concepts and techniques to provide optimal and personalized treatment for patients.