Cosmetic breast surgery
Dean Arden Field
Restorative breast surgery was first reported in the medical literature in 1893, but the development of the silicone breast implant in 1960 marked the true birth of this procedure. In the past 30 years, an estimated 2 million women in the United States have undergone implantation of breast prostheses. Approximately 700,000 have had reconstructive breast surgery after mastectomy,[2-5] and 1.3 million have undergone augmentation.[3,6] While augmentation is the procedure most frequently associated with the term "cosmetic breast surgery," the field also includes reduction mammoplasty and reconstructive breast surgery following mastectomy for carcinoma.
Although surgeons often provide longitudinal follow-up for patients who have undergone breast procedures, family physicians are becoming increasingly involved in the medical care of these patients, in part because of the growth of gatekeeper health-care systems and the mobility of American society. Thus, it is essential that family physicians understand current surgical procedures, the structural breast changes following surgery and the influence of this surgery on preventive health screening.
Reduction mammoplasty involves partial removal of breast tissue and recontouring of the remaining tissue. Patients generally seek this surgical treatment because of negative cosmetic perception and/or musculoskeletal strain on the neck and upper back. In addition to the reduction in breast size, a satisfactory outcome includes maintenance of the nippe-areola area and a lasting conical projection (Figures 1a and 1b).
Although at least 55 different procedures for reduction mammoplasty have been described over the years, most surgeons today use a variation of the inferior pedicle technique. In this procedure, the nipple-areola complex is carried on an inferior breast and skin pedicle. A less common technique carries the nipple-areola complex on a superior pedicle. In rare cases, it is necessary to remove the nipple-areolar complex and replace it as a graft, but this procedure fails to accomplish one of the goals of breast reduction, the maintenance of nipple sensation.
Early postoperative complications of reduction mammoplasty include infection, poor wound healing and pain. Sensation may be temporarily diminished, but sensory loss rarely is permanent. Even when sensory loss is transient, reinnervation may be slow and accompanied by a period of hypersensitivity. Hypertrophic scar formation, a troublesome late development and a potential complication of any surgical procedure, may disrupt the natural conical projection of the breast and cause cosmetic disfigurement. A submammary incision, rather than a vertical incision, is more frequently associated with hypertrophic scarring, perhaps due to increased biomechanical stress at this site. Overall, however, patient satisfaction with reduction mammoplasty is high.
Augmentation mammoplasty is the surgical enhancement of a patient's existing breast contour, generally by inserting an underlying implant (Figures 2a and 2b). While some may find it difficult to justify taking a surgical risk for a purely cosmetic reason, studies have reported significant psychologic improvement in the majority of patients who have undergone breast augmentation. 
Augmentation can be performed using an axillary, periareolar or submammary approach (Figure 3). Implant selection is tailored to the needs and concerns of the patient. Implant types include a doublelumen implant (a silicone gel envelope within a saline envelope), a silicone gel-filled implant, a saline envelope, a polyurethane-coated implant (no longer available), and an inflatable implant with a subcutaneous injection port. Recently, questions have been raised about the potential danger of silicone leakage from
of Capsular Contracture
Grade I: Absolutely natural; breast does not
appear to have been augmented.
Grade II: Minimal signs that surgery has been
performed, but the patient has no
Grade III: Moderate contracture; patient feels
some firmness in entire breast.
Grade IV: Severe contracture; implant is obvious.
Adapted from Grabb WC, Smith JW, eds. Plastic
surgery. 3d ed. Boston; Little, Brown, Co., 1979:
breast implants. Whether this concern is warranted is as yet unproved.
Unfavorable breast appearance is the most common postoperative complication of augmentation mammoplasty. The primary proglem is capsular contracture, the exact mechanism of which is poorly understood.  When capsular contracture occurs, a relatively a vascular sheath forms around the implant. Certain surgical techniques, such as retromuscular versus retromammary implant placement, have been shown to reduce the incidence of contracture. Grades I and II contractures are mild and are not usually detected by the patient (Table 1) . They may actually enhance the conical projection of the breast.
Silicone implants are susceptible to several problems. In late leakage secondary to "fold flaw," the encapsulating membrane breaks down at the fold site.  This flaw is uncommon with the newer implants. Of greater concer is "gel bleed," a gradual diffusion of silicone through the membrane.  The rate of silicone diffusion and its significance are poorly understood. Gel bleed was first presumed to be of little importance, since silicone is a chemically inert substance. However, some case reports suggest that an autoimmune disease phenomenon may be associated with the diffusion of silicone, creating symptoms similar to those of systeic lupus erythematosus.  Rumors that silicone may induce neoplasms have not been substantiated. 
The U.S. Food and Drug Administration has asked implant manufacturers to supply studies demonstrating the safety of all implants, since data on implant safety were not gathered originally.  Recently, the use of the polyurethane-coated implant has also been questioned, since the coating may deteriorate into TDA (2-toluene diamine), a chemical substance that has been associated with cancer in laboratory animals.  While this type of implant is no longer being inserted, there is no current recommendation for its removal. A registry has been established for follow-up of patients with these devices.
Breast reconstruction is most commonly performed in patients who have had a mastectomy for breast cancer. Breast cancer remains one of the most common female cancers, striking one out of every nine women and comprising 26 percent of all cancer cases in women.  Breast cancer poses a dual threat in the form of risk to life and the loss of female body image. As a sexually associated structure, the breast is closely linked to a woman's self-esteem.
As with augmentation, the benefits of breast reconstruction are primarily psychologic. Surveys suggest that this benefit far outweighs the medical risks of the procedure. In one study, 70 percent of patients reported improved self-image, 84 percent viewed breast reconstruction as an important aspect of their lives and 89 percent came to view the "new" breast as "real." Finally, 97 percent of patients reported they would repeat reconstructive surgery despite occasional suboptimal results. 
A prosthesis or a myocutaneous flap may be used in breast reconstruction. Depending on the amount of remaining overlying skin and whether radiation therapy was given, reconstruction involves one or two stages. In the single-stage technique, a permanent or adjustable prosthesis is placed at the time of mastectomy. In the dual-stage technique, a temporary expander is placed at the time of mastectomy, taking advantage of the skin's elastic properties to create a pocket over time. In the second stage, a permanent prosthesis is inserted into this expanded space. Either technique may include an additional stage for the reconstruction of a nipple-areola complex, generally formed from skin grafts that have color added by tatooing (Figures 4a, 4b and 4c).
The alternative to placement of a prosthesis is the use of a myocutaneous flap to create the bulk of new breast tissue. The transverse rectus abdominus myocutaneous flap technique is the favored procedure. This approach to breast reconstruction is possible only if the patient has enough soft tissue mass in the abdomen to provide the bulk necessary to form a breast (Figures 5a, 5b and 6).
The family physician is not typically responsible for initial postoperative care, but important points of management in the early postoperative months should be reinforced. Healing tissue is dyanmic, often for a period of months, and this dynamic character is a potential cause of an unfavorable cosmetic appearance. Gentle and frequent massage of the scar reduces thickening, stimulates revascularization and promote mobility and elasticity of the skin. The patient should be aware of the potential for sun-induced hyperpigmentation of the scar, which can be reduced by using a sun screen and limiting sun exposure.
During the postoperative period, the family physician can reinforce the surgeon's warnings about the risk of capsular contracture. Although the etiology of capsular contracture is poorly understood, exercises to maintain the implant pocket probably reduce the risk of this complication.  In these exercises, the patient applies moderate hand pressure to liberally displace the implants medially, laterally and superiorly, within the limits of comfort (Figure 7). Inferior displacement is usually not desirable. Implant exercises are commonly initiated by the surgeon 24 to 48 hours after the operation and should be continued for as long as the implant remains in place, since contracture remains a persistent threat.
Mammography, couple with breast self-examination and the physician's clinical examination, is an essential tool for cancer screening. The sensitivity of mammography may be adversely affected by surgical procedures and implants. 
Differentiating postoperative and malignant changes is essential following reduction mammoplasty. Mammoplasty alters breast contour and frequently causes parenchymal scarring. Scarring may confound the interpretation of a mammographic study by producing asymmetric densities or scars with spiculated margins and clustered microcalcifications that simulate mass lesions.  All such changes can be misinterpreted and lead to unnecessary biopsy. Interval change is the primary
[TABULAR DATA OMMITTED]
way to differentiate postoperative changes from malignant changes, since postoperative changes generally peak at three to six months and should become stable or resolve over time. 
Although augmentation does not alter breast parenchyma to the extent that breast reduction does, the silicone implant casts a radiopaque shadow that reduces the sensitivity of mammography.  The degree of obscured parenchyma varies, depending on the size of the preoperative breast and the size of the implant. [3,6,18] In a small breast, as much as 30 to 60 percent of the parenchyma may be lost by shadowing.  Mammographic sensitivity also may be reduced because of the location of the prosthesis. Retromammary placement blocks more parenchyma than retromuscular placement. A breast prothesis compresses poorly during mammography, contributing to further loss of detail. In the past, poor compression was partially overcome by using foam sponges during positioning of the breast, which allowed better compression, but this technique did little to eliminate the implant shadow.
Several techniques may be used to improve mammographic visualization of breast parenchyma. For example, the breast may be positioned so that the implant is secured against the chest wall and out of the field of the compression paddle.  Multiple mammographic views also increase the percentage of parenchyma visualized.
Mammography should be done following mastectomy and breast reconstruction, because of the increased risk of contralateral breast carcinoma and the importance of early detection of metastatic disease in the ipsilateral axilla.  Some experts suggest that mammography be performed every six months after mastectomy or reduction surgery for the first one to three years, in an attempt to differentiate between postoperative changes and findings suspicious for carcinoma. Mammography is especially important in the highrisk patient with previous carcinoma or a strong family history of breast cancer. Clinical examination with special attention to scars is also essential.
Both augmentation and reduction mammoplasty mandate mammography prior to the surgical disruption of normal breast parenchyma. After reduction, early serial studies are beneficial in following the normal changes of scarring. After augmentation, periodic studies are important in identifying the early changes of carcinoma, since there may be a lag in detection due to the decreased sensitivity of mammography. The recommendations for screening mammography are outlined in Table 2. [5,6,17,18,20]
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DEAN ARDEN FIELD, M.D. is a member of a multispecialty group in Phoenix. Dr. Field graduated from the University of Arizona College of Medicine, Tucson, and completed a family practice residency at Good Samaritan Regional Medical Center, Phoenix.
SANDRA MILLER, M.D. is assistant director of the family practice program at Good Samaritan Regional Medical Center. Dr. Miller graduated from Rush Medical College, Chicago, and trained in family practice at Good Samaritan Regional Medical Center.
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