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BREAST AUGMENTATION

Overview

  • Most popular aesthetic surgery procedure according to BAAPS audit

    • 4702 procedures in 2020, despite COVID-19 pandemic​

  • Popularity contributed by combination of emerging importance of body, changes in societal expectations and increasing acceptance of aesthetic surgery​

Overview

History of breast augmentation

  • First performed by Czerny in 1895 by transplanting a lipoma from the trunk to the breast after partial mastectomy

  • In 1954, Longacre described a dermal-fat flap for breast augmentation

  • Early material for augmentation include polyurethane, polytetrafluoroethylene (Teflon) and expanded polyvinyl alcohol formaldehyde (Ivalon sponge) that eventually were discontinued due to firmness, local tissue reactions, breast distortion and discomfort

  • Injectables for augmentation included epoxy resin, shellac, beeswax, paraffin, petroleum jelly and liquid silicone which were discontinued due to complications

  • Modern implants are two-component prosthetic devices

    • Silicone elastomer shell​ and stable filling with either silicone or saline

    • First developed by Dow Corning Corporation in 1962​ and known as the Cronin-Gerow implant

    • Several generations of implants have been developed with improved safety and outcomes

History of breast augmentation

Classification of breast implants

  • Size

    • Measured in volume​

  • Shape

    • Round​

    • Anatomical

  • Shell​

    • Smooth​

    • Textured

    • Microtextured

  • Filler​

    • Silicone​

    • Saline

Classification of breast implants

Patient selection

  • Open ended questions

  • Ideal size and shape

  • Explore any concerns about patient's understanding, expectations or self-esteem issues

  • General fitness, past medical history, smoking status

  • Preoperative mammogram if over age 35 years or significant risk of breast cancer

  • Examination:

    • Chest wall deformity and spinal curvature​

    • Scars and skin quality using pinch test

      • <2cm favours subpectoral pocket for implant​

    • Breast, nipple and inframammary fold asymmetry

    • Palpation for masses or suspicious lymph nodes

  • Measurements:​

    • Sternal notch to nipple distance (SN:N)​

    • Nipple to inframammary fold (N:IMF)

    • Internipple distance

    • Breast width

    • Breast height

  • Clinical photography​

Patient selection

Operative considerations

  • Incision

    • Transaxillary​

    • Inframammary

    • Periareolar

    • Transumbilical

  • Pocket position​

    • Subglandular​

    • Subfascial

    • Subpectoral

    • Dual-plane

Operative considerations

Postoperative care

  • Usually day-case procedure or overnight stay

  • Short course of oral antibiotics

  • Sports bra for 6 weeks

  • Return to work a few days after surgery

  • No rigorous exercise for 2-3 weeks

  • Clinical photography

Postoperative care

Complications

  • Early

    • Altered nipple sensation

    • Seroma

    • Haematoma

    • Infection

    • Superficial thrombophlebitis

  • Late

    • Capsular contracture​

    • Implant rupture

    • BIA-ALCL

Complications

BIA-ALCL

  • Aetiology theories

    • No consensus

    • Biofilm, chronic inflammation, genetic susceptibility, infection, surface features of textured implants providing a host environment

  • Presentation

    • Age – mean 52 years (28-87)

    • Onset of implantation – ALCL

    • 8 years (2-25)

    • Signs and symptoms

    • Late seroma – 79.3%

    • Mass – 40%

    • Capsular contracture – 8%

    • Lymphadenopathy

    • Skin rash – 2%

  • ​Diagnosis

    • Ultrasound – aspiration of seroma fluid

    • Stains for CD30 and ALK

      • CD30 positive

      • ALK negative

  • Treatment

    • Removal of implant, capsulectomy

    • Adjuvant treatment

      • Case by case basis

      • CHOP (?poor response)

      • Anti CD30 directed therapy

        • Brentuximab

      • Radiotherapy

  • ​Prognosis

    • UK 3 reported deaths

    • Only 1 confirmed to be due to BIA-ALCL

    • Others all disease free at 23 month follow up

  • MHRA/BAPRAS/BAAPS/ABS advice

    • Currently not enough scientific evidence of a causal relationship specifically between textured implants and BIA-ALCL

    • Do not recommend explantation of those patients with existing textured implants
      ​

BIA-ALCL
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