Breast augmentation with implants, fat grafting or a hybrid of both is becoming a widely accepted and popular procedure in Asia1. The most important reason for the popularity of this operation is likely the increase in self-esteem provided by breast augmentation. However, the procedure involves operating on a female organ that undergoes extensive changes over the natural progression of life. Therefore, careful planning, communication and execution of the surgery are of utmost importance to achieve the best results.

A complete medical history is essential. Age, smoking history, and common medical illnesses, e.g. cardiovascular or pulmonary disease, diabetes mellitus and hepatitis carrier status are important. The patient’s current prescribed and over-the-counter medications should be obtained. A history of pregnancies, including weight change and lactation duration, is asked with particular attention paid to her breast-related history. The history includes the patient’s history of breast disease and/or procedures, the family history of breast cancer, and the age at which they happened, if any. In patients with a family history of breast cancer in their first degree relative at a relatively young age, genetic testing for BRCAI and BRCAII genotypes should be discussed2. A mammogram and/or ultrasound of both breasts should be done as a preoperative workup for the procedure.

Physical examination, including the patient’s height, weight, and proportions, should be taken. The patient’s bra size and breast shape preoperatively, as well as any asymmetries, if present, should be noted with regard to breast volume, base width, nipple-areola position, and inframammary fold. Landmarks, including sternal notch, position of nipples, anterior axillary lines, and inframammary folds should be carefully marked for detailed measurements later. If present, the skin quality, postpartum atrophy, and stria should also be noted. General breasts and axillary examinations for breast lumps and lymphadenopathy should also be carried out.

The surgical treatment plan should be discussed thoroughly with patients regarding specific choices unique to breast augmentation, including incision placement, implant placement, and implant type and size, aiming at offering an individualised treatment. Unrealistic expectations and requests widely exceeding the acceptance of the general population should not be entertained. This practice limits the requirements for reoperations to factors beyond the surgeon’s control (e.g., capsular contracture) and enhances patients’ satisfaction. Lastly, all the discussions should be clearly documented with proper clinical photos of the patients.

Common incisions in breast augmentation with implants include inframammary, periareolar, and transaxillary. (Fig.1) In the transaxillary approach, endoscopic assistance in dissection is used for better visualisation3. All the incisions listed are currently used by surgeons performing augmentation mammaplasty, and each incision has its advantages and limitations. Regardless of the incisions of choice, there is no doubt that it should be tailored to the patient’s breast characteristics and will. For example, a periareolar approach should be used for patients who want an areolar reduction or lift, while an inframammary fold incision should be chosen for patients who want to keep injury to the breast gland as little as possible. On the other hand, a very thin Asian patient without significant breast tissue, lacking a defined inframammary fold, may be at risk for increased prominence of an inframammary scar. In general, the inframammary and periareolar approaches will provide more direct and precise pocket dissection than the transaxillary approaches unless endoscopic assistance is employed. Researchers have been looking into different complication rates with respect to the incision chosen and did not give a definite causal relationship (4 – 7).

While saline implants were once a mainstay in implant based breast augmentation due to restriction on the use of silicone gel in the U.S. from 1992 to late 20062. Currently, most of the implants in Asians are silicone implants. Since Cronin and Gerow introduced the firstgeneration silicone gel-filled implant in 1962 with a thick, smooth silicone shell, there is enormous research to improve both the safety and quality of silicone implants. Currently, most silicone implants are filled with fifth-generation cohesive gel with a tight control guided by the FDA.

Texturing of the silicone shell of implants was developed as an attempt to decrease the rate of capsular contracture8. Evidence shows that the capsular contracture rate for textured implants in sub-glandular placement is less than the rate for smooth implants, while the rate is similar in subpectoral placement. It can be divided into microtexture vs macrotexture. Macrotexture implants provide more stability and less capsular contracture rate but have more potential for bacterial growth. Some macrotexture silicone implants have been removed from the market due to this possibility of biofilm and its relationship with breast implant-associated anaplastic large cell lymphoma (BIAALCL) 9, 10.

Anatomical implants have been advocated in Asians due to the small breast size in general and the ‘fake look’ when using round implants with unnatural upper pole fullness. Also, it provides more lower pole fullness and projection in order to better define breast shape. The downside is that it does not change in shape with the patients’ posture and often remains sturdy when patients lie down. It also carries the extra burden of precision with placement, as distortion and malposition may be apparent. With advances in technology, we could now achieve better results with ergonomic implants in which the implant shape changes according to patients’ posture. If a hybrid procedure with fat grafting is performed with a smaller implant size, better palpability and shape can sometimes be very similar to natural breasts11.

Choosing the perfect size for the patients is always a challenge while it involves a lot of discussion with patients in understanding their expectations. It very much depends on the patient’s breast dimensions and tissue quality. For example, a young, thin, nulliparous lady with minimal breast tissue will make a more aggressive upsizing difficult while a multiparous lady with a history of breastfeeding will benefit from bigger implants in order to lift her breasts. The most common requests in my practice are around two bra cup size increases. More aggressive upsizing may often result in an unnatural appearance with implants alone, and I often suggest a hybrid procedure with implants and fat grafting in order to give more natural results.

Traditionally, implants are placed either subglandularly or subpectorally, or dual plane.(Fig.2) The patient’s breast shape and tissue characteristics are the two most important factors determining the choice. Studies have indicated that submuscular placements have a lower capsular contracture rate than subglandular placements12. In addition, the subglandular position places the implant closer to the skin surface, giving better cleavage but with higher risks of palpability and rippling, as well as symmastia, particularly in patients with little breast tissue, as in many Asians. Recent research suggests that subfascial placement has the advantage of improving upper pole contour, avoiding implant edge visibility, keeping the implant in place and avoiding muscular dynamics over the implants13. Dual plane is more commonly used in Asians, especially when choosing smooth implants, as the capsular contracture rate is much lower. However, implants placed at this plane may lead to the dividing and weakening of the pectoralis major muscle as well as animation deformity.

Fat transfer is another option for breast augmentation. Reasons for the recent increase in demand for this procedure are its advantages over implant-based breast augmentation, including avoidance of foreign bodies with implants and its associated complications such as capsular contracture and malposition deformity. While there were concerns about its potential complications in the past, emerging reports in the literature have proven the safety and efficacy of fat grafting to breasts because the postoperative incidence of malignancy is not increased and the limited data regarding the radiologic impact of fat grafting to breasts suggest that there is little interference with breast cancer screening (14, 15).

The ideal patient for breast augmentation with fat grafting is a patient who has abundant adipose tissue as a donor site for harvesting and a pliable skin pocket and sufficient tissue dimension that serves as a good recipient base for injection of adequate volume of graft will be well indicated for breast augmentation with fat grafting. For patients expecting a more natural change of the breast size around 120 cc to 150 cc, one bra cup size increase will also be very suitable for this procedure.

After taking a detailed medical history, patients with a high risk of breast cancer should be informed that they should pay extra attention to surveillance after the procedure. Patients who are heavy smokers should also be informed about the lower survival rate of the fat cells and advised to stop smoking before and after the procedure. After a thorough discussion and explanation of the procedure with the patients, proper clinical photos, including donor sites are taken and a consent form should be signed before the procedure.

The surgical procedure is divided into three parts: Fat graft harvesting, Fat graft processing and Fat graft injection. Fat graft harvesting can be done using different techniques. Common donor sites include the abdomen, flanks, and thighs. Higher cell concentration of lipoaspirates is reported in the lower abdomen and inner thigh in the young (21 – 37 years old) female group and they are also better donor sites for adult mesenchymal stem cells. Hence, they are often chosen as the “preferred” donor sites for fat transplantation(16).

The author prefers to perform breast augmentation with fat graft under general anaesthesia, although it could also be done under intravenous sedation or local anaesthesia. The tumescent solution used in general anaesthesia should keep the lidocaine concentration at its minimum at 0.01 % in Ringer’s lactate solution with an adrenaline concentration of 1:200,00017. Vasoconstriction caused by adrenaline facilitates haemostasis, and also decreases the chance of fat embolism by intraarterial injection of fat graft. Fat aspirate should be done under low suction pressure or with a special machine that helps preserve the viability of harvested fat cells, e.g. water assisted liposuction. High energy assisted liposuction methods are generally avoided in order to prevent lysis of fat cells, although there are reports claiming lower energy may give similar fat graft survival rates. A 1:1 ratio of aspirated fat to the tumescent solution is carried out and is allowed to set a standstill by gravity. The watery part and oil are removed, leaving the fat part of the lipoaspirate behind. The lipoaspirate is then centrifuged at 3,000 rpm for 3 minutes, as advocated by Coleman and excess fluid and oil are discarded, leaving behind the concentrated fat for injection. (Fig.3)

Placement of fat graft to the breasts requires an understanding of the anatomy and meticulous execution to distribute them evenly. The fat graft should be injected subcutaneously, behind the breast parenchyma, into and beneath the pectoralis major muscle. The author tries not to inject into the breast parenchyma to avoid further misinterpretation of breast imaging, but it is controversial and is a surgeon’s preference. The fat graft is slowly injected with a blunt tip cannula with a fanning technique through a stabbed incision at the areola, premaxilla and inframammary fold. Surgeons should advance the cannular gently into the correct plane and inject retrograde, aiming at a small droplet of fat 0.5 ml. Care is taken not to inject repeatedly in the same area18. In that case, the survival rate of the fat is greatly enhanced and complications, e.g. oil cysts and calcified fat, is avoided. On average, every breast augment breast augmentation session with fat graft should be limited to 150 to 250 cc on each breast side. For Asian ladies with breast circumference of 80 cm at its inframammary fold, 150 to 250 cc injection would approximately be one bra cup size increase. In patients who desire more aggressive upsizing, surgeons could either repeat the procedure in six months or combine it with an implant as a hybrid procedure.

Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a relatively new and uncommon entity that was only first reported in 1997. It has been treated with aggressive therapies, similar to cutaneous lymphomas, until recently when we have gained a better understanding of its characteristics and formulated its own treatment category.

The diversity of presentations warrants high alertness to all medical professionals who deal with patients having implant-based breast augmentations. Need to consider and rule out this diagnosis in patients with textured implants or a history of such devices or those who exhibit symptoms like late seroma, breast swelling, capsular contracture, or peri implant mass19. And then the patient should be examined by comprehensive breast imaging, employing either ultrasound (US) or magnetic resonance imaging (MRI). A fine needle aspiration (FNA) of at least 50 cc is carried out if peri implant collection is found and sent for an assessment of cell morphology through cytology, presence of CD30 and anaplastic lymphoma kinase (ALK) expression via immunohistochemistry, and an evaluation, quantification, and characterisation of T cells and additional biomarkers through flow cytometry. Tissue biopsy should be carried out in case a solid tumour is detected on imaging (20).

Once BIA-ALCL i s conf i rmed, di scus s in a multidisciplinary meeting, includes oncologists, breast surgeons, breast imaging specialists, pathologists, and plastic surgeons. Positron emission tomographycomputed tomography (PET-CT) scans are a useful preoperative tool for proper staging of the disease. The treatment approach involves “en bloc capsulectomy”, which is the main determining factor of the treatment response rate21. Surgically excised tissue and aspirated fluid are subsequently sent for further analysis to determine the tumour margins and pathological disease stage.

In summary, breast augmentation has evolved through the past decades and remains one of the most popular plastic surgeries. With recent advances in techniques and technologies, we should continue to strive to give our patients the safest and best outcome possible.

References
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