If you have had and augmentation and want to breastfeed, or are breastfeeding and thinking of an augmentation, or just curious...

If having read this article and still have more questions, please pm a moderator/ email us or ask the experts in the chat forum -we'd be happy to answer your questions.

Implants - which one?

Implants have been used since the 1960s to enhance and enlarge the shape of female breast tissue. Currently, they are the preferred approach for augmentation mammaplasty. First used in 1964, when reported by Cronin and Gerow, silicone still is used for augmentation of female breasts. The advantages of silicone-filled implants include minimum solubility of the silicone and excellent viscosity of the material, providing an excellent feel to the breasts. Autoimmune responses have been reported regarding silicone implants in breast augmentation. These were discredited because of a number of exhaustive long-term studies that failed to demonstrate increased incidence of long-term problems in large numbers of women who underwent augmentation with silicone implants..

When the Food and Drug Administration (FDA) temporarily removed silicone implants because of purported increased incidence of autoimmune phenomena, a considerable amount of interest arose regarding the use of saline implants to augment breast tissue. Saline-filled implants have been used since the 1960s. Saline is absorbed safely into the bloodstream if a loss in the integrity of the implant capsule develops.

Saline implants purportedly have a decreased capsular contracture rate when compared with silicone implants. However, saline has slightly decreased viscosity compared to silicone. The initial use of saline implants resulted in a high incidence of deflation (approximately 10%). Over the last 10 years, significant work by implant manufacturers to improve the integrity of implants and specifically to improve the reliability of the valvular mechanism for introduction of saline into the implant has resulted in deflation rates that are predicted to be less than 1%.

After having been removed from general use by the FDA, silicone implants have been exhaustively studied and have been shown to have low complication rates comparable with or, in some cases, lower than those of saline implants. The FDA subcommittee on silicone implants has recommended that silicone implants be reintroduced in the United States. Silicone implants were never removed from the European market.

So, in short, silicone is still the favoured implant, and has not been associated with any major issues hence its still current use among plastic surgeons in Ireland.

Breastfeeding and augmentation surgery.

Breastfeeding after breast augmentation surgery is absolutely possible. Most women have some milk, but some may not have a full milk supply for at least the first baby. However, every drop of milk is tremendously beneficial for your baby (see 100 reasons) and there are many ways to increase milk production.

The original state of the breasts prior to augmentation is very important in predicting how much milk a mother can make after breast augmentation surgery. Although small breast size alone is not a risk factor for low milk production, certain breast types are known to be risk factors for insufficient glandular tissue. These types include tubular-shaped breasts, widely spaced breasts, undeveloped breasts, and asymmetrical breasts (due to Poland’s syndrome or breast hypoplasia/ asymmetry. When little glandular tissue exists to begin with, milk production capability is significantly reduced even before the surgical procedures occur.

Unfortunately, most women report that they are not advised that they may have an inherent lack of glandular tissue or that breast augmentation can reduce their ability to breastfeed. As with all breast surgery, cutting ducts or nerves will result in lower milk production. The location, orientation, and extent of the incision determine how much milk production will be affected. Surgeons often attempt to minimize scarring in breast augmentation surgery to improve the aesthetic appearance of the breast by placing incisions in less visible areas, such as on the areola or underneath the breast in the inframammary fold. An incision on or around the perimeter of the areola, particularly in the lower outer quadrant, will result in reduced nerve response to the nipple and areola, significantly reducing milk ejection, which in turn reduces milk production .

Placement of the implant can also affect breast function. An implant positioned directly under the glandular tissue is more likely to put pressure on the glandular tissue or structurally impede milk flow, resulting in reduced milk production over time, as compared to an implant positioned under the chest muscle away from the gland.

Implants may be placed by a number of routes that typically vary with surgeon preference and experience. The individual's desired results may influence the site of implant placement. The location of the augmentation incision has a direct bearing upon milk production capability. An incision around the areola or across a portion of it will reduce nerve response more than an incision under the breast or in the armpit.

Inframammary approach (under the breast)

An inframammary incision is the most common approach for placement of a breast implant. This approach, which entails a 3- to 4-cm incision, places the incision beneath the inframammary fold (IMF) (directly und the natural fold of the breast). This is the most popular approach in Ireland. The inframammary approach provides the most direct route and, in general, requires the least operative time for placement of the implant. Problems associated with inframammary incisions include a visible scar on the anterior surface of the breast. There is less impact to milk production with this augmentation technique because neither the glandular tissue nor innervation is affected. However, if the implant is placed on top of the pectoral muscle, it can exert pressure on the ducts and glands, which may reduce milk production.

Periareolar approach (around the areola)

Implants placed by an incision within the pigmented areolar tissue, referred to as a periareolar incision, often result in the least conspicuous scar. However, dissection of the pocket required for implant placement is more difficult. Incisions placed through the breast tissue or in the subcutaneous plane are associated with microcalcification and cyst formation. Medial placement of the periareolar implant incision within the areolar avoids the fourth intercostal nerve, which supplies sensation to the nipple and areola.

Placement of the implant in this location results in considerable duct, glandular, and nerve damage, carrying significant risk to milk production. Ducts and glands are likely to be severed because the incision penetrates deeply through the breast tissue. If the implant is placed above the muscle, it may further impede milk production functionality by placing pressure upon the glandular tissue.

Transaxillary approach (armpit)

Placing incisions in the axilla, referred to as a transaxillary approach, avoids placement of the scar on the breast. The transaxillary approach provides the worst exposure for placement of the implant, which is a disadvantage. This may be avoided using special instrumentation, including endoscopes and specific surgical instrumentation designed to aid the dissection. An increased incidence of paraesthesia(altered sensation) involving the nipple-areolar complex (NAC) exists with this approach. Obtaining symmetrical pockets is more difficult, and damage to the intercostal brachial nerve as well as subclavian venous thrombosis has been reported. Additionally, if infection results, removal of the implant may require conversion of the transaxillary incision to one of the other incisions listed above. Hypertrophic scar formation also can occur in the axilla, and the incision may be visible when the patient wears a sleeveless dress and elevates her arms. The impact on milk production is usually minimal because the glandular tissue and nerves are largely undisturbed. As with the other incision techniques, placement of the implant above the muscle will result in greater impairment than placement underneath.

Periumbilical approach (bellybutton)

A periumbilical approach, involving placement through the umbilicus, can be used for augmentation of the female breast. Placement of the implant is restricted to a prepectoral plane, and this approach provides the worst control for dissection of the pockets. Superior dissection and symmetry of placement are difficult, even in the most experienced hands. Complications of haematoma or infection require conversion to one of the other incisions for implant removal. Additionally, placement of saline-filled implants through a periumbilical approach requires a special type of valvular mechanism. In this technique, no incisions are made on the breast or into the breast tissue, although the breast tissue is disrupted and sometimes damaged as the implant is brought into position. It also permits placement only above the muscle. This technique preserves glandular function and nerve response so that the impact to milk production is usually minimal. This requires your surgeon to be well experienced in this technique as it is tricky to place the implants well.

Endoscopic breast augmentation – detailed description

http://www.emedicine.com/plastic/topic122.htm

Implant placement

Implants may be placed directly beneath the mammary gland or in a plane below the pectoralis major muscle. Advantages attributed to placement below the gland include ease of dissection, predictable sizing and contouring, and satisfactory results provided capsular contracture does not occur. Placement of larger implants in a subglandular position than in a submuscular position is also feasible .

Submuscular placement of implants was developed in response to problems associated with subglandular placement, specifically, capsular contracture and visibility of the edge of the implant. Additional benefits attributed to submuscular placement include reduced sensory changes in the nipple, decreased rates of capsular contracture, and ease of interpretation of mammographic studies. The submuscular plane is avascular, and incidence of hematoma may be reduced by placement in the submuscular plane.

Disadvantages include potential limitations on the size of the implant, increased postoperative pain, and the possibility of lateral displacement of the implant. In addition, obtaining significant cleavage is more difficult with submuscular placement. If significant cleavage is desired, detach the inferior portion of the pectoralis musculature from its sternal attachments. This results in increased postoperative discomfort.

Further information:

Subglandular breast augmentation:

http://www.emedicine.com/plastic/topic117.htm

Submuscular breast augmentation:

http://www.emedicine.com/plastic/topic120.htm

References

http://www.emedicine.com/plastic/topic500.htm

Silicone gel mammary prostheses: immune pathologies and breastfeeding.

Neifert, M., Seacat, J., Job, W. Lactation failure due to insufficient glandular development of the breast. Pediatrics 1985 Nov; 76:5 823-8

Spear, S., ed. Surgeries of the Breast: Principles and Art. Philadelphia, PA: Lippincott-Raven, 1998.

Neifert, M. Breastfeeding after breast surgical procedure or breast cancer. NAACOGS Clin Issu Perinat Womens Health Nurs 1992; 3:4 673-82.

Hurst, N. Lactation after augmentation mammoplasty. Obstet Gynecol 1996 Jan; 87:1 30-4.