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Breast surgery
Consider all options for reconstructive,
therapeutic and esthetic procedures
AN INTERVIEW WITH Mitchell Brown,
MD
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What's the
GP's role in respect to breast surgery?
Esthetic and reconstructive breast procedures are some of the most
common surgeries performed by plastic surgeons today. According
to the American Society for Aesthetic Plastic Surgery procedural
statistics (no such statistics exist for Canada), breast augmentation
was the second most commonly performed cosmetic procedure in 2006
-- accounting for > 383,000 surgeries. Breast reduction is reported
to be the fifth most common cosmetic surgical procedure (145,000),
followed by breast lifts (126,000) and male breast reduction (24,000).1
With a growing number of women diagnosed with breast cancer, there
are more and more candidates for reconstructive surgery after cancer
therapy. These women are looking to their primary care physicians
and surgical specialists for support and advice.
General practitioners (GPs) can play a very
important role in counselling and advising their patients on issues
of plastic surgery of the breast. They can act as an initial resource
for information about surgical options for reconstructive as well
as primarily esthetic concerns. Following breast surgery, most plastic
surgeons will continue to monitor and follow their patients closely;
however, GPs must also have an understanding of how various surgical
procedures can affect long-term breast health. They need to know
what modifications may be necessary for issues such as lactation,
breast cancer screening and post-surgical imaging of the breasts.
Who are the
candidates for breast augmentation?
Generally, women who consider breast augmentation fall into two
main demographic groups. The first are young women in their late
teens or 20s who feel that their breast development is out of proportion
with the rest of their body. For these patients, the issue is generally
about size. Other reasons that young women may consider breast implant
surgery would include congenital breast asymmetry or a congenital
abnormal development of the breast affecting both size and shape,
such as a tuberous breast deformity (Figure
1).
The second group of women who consider breast
implant surgery -- and who may in fact be the most common group
seen by plastic surgeons -- are those in their 30s, 40s and 50s
who have had children, perhaps breast-fed, and may have had significant
fluctuations in their weight. For these women, the issue is more
about shape and firmness of the breast than about size. They will
often describe their breasts as looking deflated and empty, and
they may have a great deal of difficulty finding clothes that fit
without padded inserts. The goal is often to restore what was there
before pregnancy, without producing the stereotypical "breast implant
look."
Women who are considering breast implant surgery
should consult with a plastic surgeon and be prepared to discuss
their motivations, goals and expectations. Good candidates for surgery
are women who are healthy and have had no significant medical problems
with their breasts in the past. The primary motivation must be that
they are doing the procedure for themselves. In carefully selected
patients, breast augmentation surgery can have an extremely positive
impact on a woman's self-confidence, body image and self-esteem.
When surgery is being sought to help a failing relationship or to
change a career path, patient expectations are rarely met. All women
undergoing elective breast implant surgery should have a complete
breast examination performed prior to surgery, and a screening mammogram
is recommended for women over the age of 40.
What's involved
in the procedure?
Breast augmentation surgery is generally performed as an outpatient
procedure, either under general or twilight anesthetic. Women will
usually return to normal non-physical activities within a week,
but are asked to avoid heavy physical activities -- such as lifting
or sports -- for 1 month.
Breast implants can be placed in one of two
locations; subglandular, i.e. on top of the pectoral muscle, or
subpectoral, i.e. below the pectoral muscle. The decision as to
where to place the implant is based on a variety of factors that
include the quality and quantity of breast tissue, the shape of
a woman's breast and the desired shape post-op. In order to insert
a breast implant, a small incision is required. The most common
location for this is in the crease under the breast -- other options
include the border of the pigmented areola and the apex of the axilla.
Although described, insertion of an implant using endoscopic technology
through an incision in the umbilicus is generally not advised due
to the significant risk of asymmetry and implant trauma upon insertion.
What types
of breast implants are available?
There are two main types of breast implants used today. Saline breast
implants have a silicone elastomer rubber shell and are filled with
saline. They are generally inserted while deflated and are filled
through a connecting tube once they've been placed under the breast.
For this reason, the incision can be kept quite small, usually in
the range of 2.5-3 cm. Saline implants can provide excellent results
in properly selected patients; however, in women with ptosis and
minimal tissue cover, saline implants may not be the ideal choice
as they can produce palpable and visible edges that aren't esthetically
desirable. For these patients, cohesive silicone gel breast implants
may be a better choice -- they have a similar silicone elastomer
shell, but are filled with silicone gel.
The silicone implants that are used
today have a more viscous, thicker gel than those used in the 1970s
and early '80s. They're often described as "gummy bear" implants
because of the similarity of their internal consistency.2 Cohesive
gel implants come in round styles as well as a variety of anatomic
shapes, allowing the surgeon to select a shape that will most naturally
augment the breast (Figure
2). They have a softer feel than saline implants and are less
likely to produce abnormal rippling around the periphery of the
breast. Selection of the appropriate implant can only be made after
a thorough evaluation of breast shape, size and consistency and
a detailed discussion of risks and complications associated with
each device.
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