Breast augmentation is the most common aesthetic procedure worldwide and as such it is often perceived as a simple procedure, where the same technique is applied to every patient. This is a common misconception – as with any procedure, the technique needs to be tailored to each patient’s individual needs. My clinic has recently become a referral centre for revisionary breast augmentation procedures and I have been shocked at some of the things I am seeing, all of which would have been easily avoidable had the patient been aware of all the options available in the first place. There are many important decisions that need to be discussed, often during multiple consultations, to determine the most appropriate size and shape to give a long lasting natural result.
The size of the implant is determined by the width of the implant base, the implant height and the implant profile. Although patients will request certain cup sizes, the width of the chest wall is the most important factor in determining the maximum size of implant possible. Once the base diameter or width has been assessed, the height of the implant and the profile of the implant can be altered to give the overall shape. Shape is altered by not only the implant but the anatomical position of the sternum, the height of the chest wall and the position of the nipple or breast tissue. Nipples and breast tissue can be lifted using certain implant shapes and/or by altering the position of the inframammary fold on the chest wall. Certain implants can be chosen to create fullness in the top or the bottom of the breast. One of the most important discussions centres around the sternum and the width of the sternum in relation to the muscle insertion.
It is this anatomical position that determines how the implants will sit to create the cleavage. Often patients request ‘overs’ or ‘unders’, i.e. implants positioned either over or under the muscle. A careful examination of the amount of breast tissue, the location of the pectoralis muscle and the position of the sternum will dictate the pros and cons of the pocket placement. The benefits of ‘unders’ are that the implants at the top and in the cleavage have more coverage with a muscle layer and so there is less chance of feeling the implant. ‘Overs’, although more prone to be palpable at the top and in the cleavage area do allow one to create less of a gap and more of a cleavage, especially in a bra. A combination of both these techniques, called a ‘dual plane’ technique, allowing a more reliable positioning of the breast tissue than the solely ‘under’ technique, has become the preferred method when a patient wants to have the implant under the muscle or has minimal breast tissue. It still has a tendency to produce slightly more of a gap in the cleavage area. If the breast tissue and nipple lie below the level of the inframammary fold then it is important to discuss the benefits of a mastopexy at the same time as a breast augmentation and patients consulting for breast augmentation should consult with experienced surgeons with experience in mastopexy implant to obtain a full understanding of the limitations of breast augmentation alone. This will avoid the need for revisionary procedures at the outset. Revisionary procedures are extremely rare if the correct implant and the correct technique are performed. This often requires multiple consultations to determine the individual needs and expectations of each and every patient.