Aesthetic Breast Surgery into Next Millenium II

Whenever we talk of female beauty, breast is invariably associated as one of its attributes. Why? Our first food after  birth comes from the breast, raises an eternal bondage according to the Freudian philosophy.

The idea of the beauty has changed over ages, in different cultures and at various stages of civilisation, along with its individual perception. This is mainly related to facial aesthetics and body contour. Seldom much is talked about breast- except that it is ornamental in a female, as much as it is the first contact between a mother and a child after birth.

Figure 1: Over-augmented Breast

We know that the breast extends from 2nd to the 6th rib, from mid-axillary line to the sternum and it develops on the mammary line. This is as far as the anatomy is concerned. But what about the aesthetics?

Figure 2: Correctly Augmented Breast

Figure 3: Venus of Palaeolithic Age

In recent years I have endeavoured to project the aesthetics of the female breast to the international community. Though Pamela Anderson or Dolly Parton may have an attraction(?) to the male eye, yet no artist or sculptor would attribute those breasts as the epitome of beauty[1]. If we look at two augmented breasts, which looks normal? In Figure 1 the breasts have been over-augmented and also it shows sagging of traditional prosthesis with gravity. In Figure 2 the augmentation  is balanced  with the natural drop. Also it's ‘proportions to  the body’ (Figure 3)  of the individual ( i.e., height, structure, girth etc.) has to be considered, when visualising the outcome.

Figure 6: Bronze Figurine

The first and foremost  is a philosophy, that there is a gradual droop of the breasts with age. The breast of an eighteen year girl and that of a fifty-five year old lady is not the same. This natural droop with age forms the aesthetic basis of performing breast surgery.

Figure 4: Indian Sculpture

On the lateral profile the line from clavicle to the nipple must be straight line, rather than an obvious convex curve. This fact is substantiated by the painting of Radha (Figure 5) or an extract from  Indian sculpture (Figure 4) or from a bronze figurine (Figure 6)

Figure 5: Radha

Aesthetic Surgery is an art and the success of the cosmetic surgeon lies in the fact that the profile is enhanced, yet nobody can recognize that the lady underwent cosmetic surgery. This is where the natural aesthetics of the breast should be taken into account. The other factor, while performing this surgical art- is not only the immediate result, but also its long term aesthetics. Gravitational changes with aging do play an important role together with the intrinsic changes as skin elasticity, fine epidermal lines, ultra-violet changes (if one happens to be a topless sun worshipper!) and pigmentary changes specially in a person with dark skin, also cannot be ignored.

That the fashions of performing breast surgery are changing, is reflected in our human beings’ eternal quest for a change due to our inherent dissatisfaction with what is present. But it is good to remember the golden words of Euripedes (484-406 B.C.) that moderation is the noblest gift of heaven.

This forms the aesthetic framework of the art of breast surgery into the next millennium. Aesthetic breast surgery consists of:

  1. Breast Augmentation
  2. Breast Reduction & Mastopexy
  3. Correction of Unequal Breasts
  4. Correction of Accessory Breasts
  5. Correction of Inverted nipple
  6. Correction of Gynaecomastia

1.  Breast Augmentation

When analyzing this popular procedure the key issues that come to one’s mind is “What do we insert?” and “Where?”

Czerny[2] from Heidelberg is generally accepted to have performed the first

augmentation mammoplasty in 1895. Since then, a variety of nonsilicone materials have been injected or implanted to augment or to reconstruct the hypoplastic female breast, including autologous tissues, intramammary- or  submammary-injected alloplastic materials, and preformed alloplastic materials other than silicone. For various reasons, none was fully acceptable. The introduction of the medical-grade silicone bag prosthesis in the early 1960s improved the results of mammary augmentation dramatically and reduced the incidence of fibrous contracture and implant extrusion. Other methods of breast augmentation became obsolescent.

Silicone has been a long stay as the only safe, inert material. What actually is it? Silicone is a family of chemical compounds with many common uses.  We use items containing silicones every day without even realizing it.  The special qualities of silicones make them ideal for many items, from medical implants and instruments, to hand lotions and lipstick.  Even some of the foods we eat contain silicones.

Silicones are made from silicon, found naturally in sand, quartz and rocks.  Next to oxygen, silicon is the most common element in the earth’s crust, and like oxygen, both animal and plant life depend on silicon.  Silicon becomes silicone when it is combined with oxygen, carbon and hydrogen.  Depending on how the silicone molecules are arranged, silicone can be manufactured into a variety of forms, including powders, gels, oils, and elastomers. Silicon elastomers  are conversion of the natural silicon into a semi-solid gel form, which gives the particular ‘feel’ of the breast.

Breast prosthesis comprises of an outer shell of silicone sheet and an inner filling of silicone elastomer. It has sustained so many modifications in its shape and form, right from a circular umbrella like cone to the anatomical variety of today. First and foremost was the shell - which initially had a smooth surface ( still unfortunately used by many of the plastic surgeons here). This gave rise to a high degree of capsular contracture rate amounting to 45% - and we saw a jump from 80’s to 90’s to the textured (rough surface) shell, where the capsular contracture dramatically fell to 5-9%.[3] [4] [5] [6] [7] [8] [9] In between we saw an upsurge of polyuerthrane coated[10] [11] [12] [13] [14] ones to decrease capsular contracture. Later on it proved to be carcinogenic and was abandoned. This was replaced with MISTI Gold[15] prosthesis, which again fell out of repute.

The next came the filling. Silicone was performing well until in early 90’s the famous litigation in USA with Dow Corning -the main supplier of the elastomer, where the American Court awarded  seven million dollars to a lady affected by auto-immune disease, which was attributed to silicone seepage. At that stage, there was no medical evidence to prove or disprove[16] this and FDA banned[17] [18] silicone filled prosthesis only in USA, though the shell was still of silicone. However in other parts of the world including United Kingdom, silicone was still routinely used without any adverse effects.[19]

To compensate for this ‘silicone bar’ in USA, saline filled varieties as Becker[20] to 133, 163, 363[21] came in market. In the midst of the ‘silicon controversy’ another group started filling the prosthesis with soya bean oil and  Trilucent implant[22] was born. One problem with these new varieties was that the ‘feel’ was not normal, as it was with silicone and the shell fracture[23] was significant.

Figure 7: McGhan's Different Varieties of Anatomical Implants

Another big problem with all these -- be it silicone, saline or Trilucent were the fluid nature of the filling. Under gravity they all gravitated inferiorly resulting in total distortion of the superior pole. This also resulted in loss of projection, which is of prime importance in augmentation. To compensate these drawbacks a new silicone hydro-colloid semi-solid gel came into market. The shape of outer covering changed from moderate to low profile and ultimately merged into an anatomical shaped one, combined with a hydro-colloid filled semi-solid gel -- which is the best available in market today. In the meantime a study on a huge section from USA in 1996[24], proved silicone had no relation to auto-immune disease and further studies are going on.

Figure 8: Breast Prosthesis Placement

The other question was where to insert? This was to do with capsular contracture. Sub-mammary to sub-pectoral are both accepted methods of treatment. My personal preference would be for the sub-mammary one as to sub-pectoral insertion, to give it proper natural aesthetics. Moreover sub-pectoral includes detachment of medial fibres of pectoralis, which causes more bleeding[25] and hence increased risk of contracture.

Having performed significant number of endoscopic breast augmentations[26] [27] [28] [29] [30] [31] [32] [33] [34] [35] via umbilicus or trans-axial route- I would say, it may be a new method, but not the best one. Firstly you have to introduce a saline filled prosthesis and the ‘feel’ is not just good. Secondly the pocket is not adequate to ensure the normal aesthetics and thirdly the infra-mammary fold is distorted specially by trans-umbilical route.

Today the philosophy of breast augmentation -- is not a volumetric expansion, but an increased projection at the right level on a correct base: to give the desired cleavage.

2. Breast Reduction & Mastopexy

Figure 9: Breast Reduction - An Artistic Concept

Large breasts may be attractive to some male eye, but it causes enormous inconvenience to the victimized female. In addition to breast pain it also causes shoulder, neck and back pain. Getting the right cosmetic clothing (bra etc.)[36] to turning from one side to the other or carrying out gymnastics, it is a nuisance to the person who develops this hypersensitivity of the estrogen receptors during puberty. The social comments to the downward fixation of a male vision in a discourse - shatters the identity.

To alleviate this problem[37] though amputation of the breast may have started the reduction technique, yet it was RS Wise in 1956[38] who suggested the key-hole pattern of reduction.- to give it the cone shape. Breast is a cone and its reduction must be in a three-dimensional plane. The other issue was preserving the blood-supply to the nipple-areolar complex, which is supplied from all sides. In came techniques of Duformental[39],b-Reduction[40], McKissock[41], Pitanguy, Skoog[42] ,  Strombeck[43], Robbins[44] etc. and all breasts landed with a standard Wise pattern of inverted T-shaped scar.

Breast reduction entails reduction of the breast and correction of skin envelope, whereas mastopexy is correction of the skin envelope only. That in breast reduction two different entities play a role individually and each must be addressed in its own merit brought a new dimension to the philosophy of breast reduction.

Reducing the scarring was the next phase in the agenda and Mouly[45] aimed at an oblique scar, while Rudolf Myer[46] aimed at an L-scar. Several others gave their own ways[47] [48] [49] to this concept. It was Daniel Marchac[50] who proposed reducing the infra-mammary scar at the cost of compensation at nipple-areolar complex level. The ideas of Mouley and Marchac were further modified by Lassaus[51] [52] [53] [54]into a vertical scar, which was popularized by Lejour[55] [56] [57] [58].

Several other techniques as axillary approach[59], Erich Lexter’s Mammoplasty attempted by Hinderer[60]  were born and pedicles were switched, sometimes keeping the vertical scar[61] [62]  or converting Marchac’s superior pedicle to an inferior one and in came the SPAIR technique[63] to play its harmony in the symphony of breast reduction orchestra. Some other techniques as horizontal scar[64] and liposuction[65] [66] of the breast were tried and died even before they were born. Breast is a fibro-fatty-glandular organ - and liposuction can only remove the fatty element, but not the other two.

With the establishment of the evidence that nipple areolar complex  is supported by a central posterior core of blood vessel (Levet[67] [68]) and the fact that the breast is a combination of two key issues- the breast tissue itself and its skin envelope, [69] Savaci proposed a peri-areolar reduction[70]  which was later modified by others[71] [72] [73]. These secondary concepts were essentially an admixture of Marchac’s concept adapted to a peri-areolar route. In my experience,  the problem is when there is no dermal support following peri-areolar reduction, under the influence of gravity and the lateral pillars falling apart as stitches dissolve or give way, the breast in no time loses its projection and assumes a male form. Savaci’s idea was further developed by Wuringer [74] to hold up the breast against gravity. Later other techniques[75] as trap-doors under pectoralis were tried to achieve this goal. Trap dooring the pedicle in-between pectoralis is a dangerous proposition and may put the vascularity of the nipple-areolar complex unnecessarily to risk. Other methods to hold the breast up are being experimented.  Though the idea of superficial fascial system (SFS) [76] suspension looks great, theoretically, it does not have enough strength against gravity. On the other hand Frey’s idea[77]  looks more promising , but in breasts where reduction is minimal, getting enough length of the skin for suspension can be a problem. Moreover whatever stitch is applied to pectoral fascia or periosteum , under the influence of gravity it tends to give way. The only secure place is a wrap around with the rib and costal cartilage. Lindquivist’s bio-absorbable screws to secure this with rib may be the answer.

I remember Carlos in the International Society of Aesthetic Plastic Surgeons meet propose in presence of Levet the first concept of peri-areolar reduction on a central pedicle wrapped with a vikryl mesh, though while writing this resume I could not see any publications to that effect.

The question is how long does this lift last against gravity? In the long run will it stay as you have raised it with surgery? This is the key question into the next millennium. A reduced scar, i.e. peri-areolar, with either sling, mesh or a fascia to hold it up  is the way forward into the 21st century. Has anyone thought about a free fascial transfer?

3. Correction of Unequal Breasts

Unequal breasts[78] [79] may be due to an underdevelopment of one breast or over-development of the other. Basically the decision is of matching the two. Depending on the size the patient wants, one breast can be reduced or the other augmented, - in most cases, it is the combination of the two to give it the right size and aesthetic shape. In most cases, where a reduction is deemed, I tend to carry out a peri-areolar reduction which gives the best cosmetic results.

Usually the hypoplastic breast is often associated with a condition called tubular[80] [81] breast. Here not only is the breast hypoplastic, but also the base diameter is very narrow. Though there are some one stage operations[82] [83] to correct this primarily, the results are not very good. In these cases volumetric increase of the size would not give best aesthetic result. The aim is to increase the base diameter[84]. This can be achieved by a expander-prosthesis as a Becker[85] or expand the breast[86] [87] [88] [89] [90] in the first instance and later insert the right sized prosthesis to balance the contralateral side

4. Correction of Accessory Breasts

Figure 10 : Accessory Breasts

Though there is a theoretical possibility of accessory breasts developing anywhere on the milk ridge, in reality it is usually  a single or a pair that is mostly found in the axilla. Sometimes it may be mistaken for a lymphangioma or even a part of the breast. Liposuction has been tried. However where the fibroglandular component is predominant, excision either open or endoscopic remains the only alternative.

5. Correction of Inverted Nipple

Nipple has two important roles in a female. As much as it is sensory to the sexuality of the female, it is the vehicle of transport of the breast milk to the hungry infant. Understanding inverted nipple associated with an underlying pathology needs correction of the underlying condition. In idiopathic cases  initially different operations[91] [92] [93] [94] [95] [96] [97] [98] [99] were described. All operations of correction of this condition caused so much scarring, that it interfered with lactation[100].

While I was in training, my Consultant Mike Gipson gave us the idea that this could be corrected by a constant  vacuum suction and made an ingenuous device with a syringe to achieve this. Later on my colleague Douglas McGeorge marketed it as a commercial device called ‘Nipellete’[101].

Though most of these are curable by Nipelllete alone , still in severe refractory cases surgery [102] [103] [104] [105] [106] [107] [108]might be the only alternative.

6. Gynaecomastia

One of the serious malaise that has effected modern western world is the mania of publications. Before one has any clue of the subject, a publication is born. In most cases the thought process is blocked and there is a compulsive socio-career oriented compulsion to publish. Invariably this lands up with lot of junk or the repetition of same idea again and again and again.

In case of gynaecomastia the number of publications[109] [110] reflects this fact. The original operation of removing breast by a subcutaneous mastectomy[111] [112]underwent several modifications of approaching the breast tissue either by an infra-mammary route or axillary route [113]   or through or around the nipple[114]. All these techniques[115] [116] [117] [118]  were basically aiming at a position of hiding the scar.

There are few basic questions to be answered before we step in to manage gynaecomastia:

  1. What is the grade[119]  of gynaecomastia?
  2. Do we remove breast tissue only, or adjust the skin with it?
  3. Is the breast predominantly of fatty tissue  or fibro-glandular tissue?
  4. What is the best way to avoid scars?
  5. How to prevent the saucerisation to give cosmetically good results?

Before contemplating surgery, these questions have to be answered.  Grade I gynaecomastia can be treated with reduction of breast tissue, but Grade II (sometimes) and Grade III (always) requires skin excision alongside.

Liposuction[120] [121] [122] [123] [124] [125],  as the only treatment is applicable to fatty breasts in Grade I and early Grade II gynaecomastia.

In other cases excision must be performed. The choice of approach is individual. I tend to use a superior pedicle[126] based peri-areolar[127] [128] [129] approach[130]  and reduce the skin[131] [132] if needed. The removal of breast is an art. Anterior approach to the breast invariably results in saucerisation. Sometimes this can be masked by adjuvant peripheral liposuction[133]. Over-reduction at nipple-areolar complex can cause severe nipple retraction[134]. I use a posterior approach, my own technique[135], which has uptil now produced consistent cosmetic results.

In Grade III ‘giganto-gynaecomastia’ [136] [137] [138]  an inferior[139]  or superior pedicle technique or bipedicled technique [140] or even a free nipple transfer[141]  may be necessary.

In fibro-glandular breast which does not need skin excision, I use the endoscopic technique[142].

Fashions will change. The process of describing yet another technique will go on [143] [144] .

Figure 11: Rene Margaritte’s 'The Rape'

Breast is an intensely personal organ of a lady - and there is a relationship of this femininity to her soul. So whenever a surgeon attempts to perform this surgery, let us remember that we are playing with her femininity - and surgery done in the wrong way, is a monstrous abuse of her femininity. Changes may come and go, fashions of performing breast surgery may change further in the next millennium, but the eternal philosophy of human psychology in relation to this organ will not change. Even before attempting to put a knife in it, one must always remember, they are delicate and must be dealt with expertise, professionalism, aesthetics and art. Maybe Rene Margaritte’s concept of ‘The Rape’(Figure 7)  will emerge as the epitome of normality one day and challenge the present concept. Until that time the patterns of performing aesthetic breast surgery will re-fashion, re-model and re-vibrate around the rhythms of the present philosophy.

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