Breast augmentation

Breast augmentation (also called mammary augmentation) falls into the fields of plastic reconstructive surgery and gynecology. The operations are usually performed for purely aesthetic reasons. If there is a disfiguring malformation of the female breast, the operation is medically indicated. This also applies to breast reconstructions after amputation, for example due to cancer (diseases in the sense of the Social Security Code).

In Germany, an estimated 15,000 to 20,000 breast augmentations are performed annually, and according to implant manufacturers, 30,000 to 45,000 breast implants are sold in Germany each year. The costs for a breast enlargement are generally between 4000 and 7000 Euros, whereby health insurance companies only reimburse such services if there is a "medical necessity". This necessity must be clarified individually depending on the clinical picture.

The implants used for breast augmentation are medical devices according to the Medical Devices Act.

Due to several serious incidents (burst implants, etc.), these have been upgraded to Class III (the highest risk class for medical devices) throughout Europe.

The average age of the patients decreases continuously from year to year. Half of the women operated on in 2005 were under 25 years of age and 2% were under 18 years of age. In 2010, 68% were under 25 years of age, of which 9% were under 18 years of age. At the same time, the overall average volume increased from 320 cm3 (ml) to 495 cm3, and in younger women (under 25 years) from 270 cm3 to 510 cm3.

Breast augmentation should not be confused with pectoral augmentation in men, where implants result in permanently more definition of the pectoral muscle. However, both operations are similar.

History

Doctors have been dealing with the reconstruction of the female breast since the nineties of the 19th century. In 1895, the surgeon Vincenz Czerny was the first to transplant a fat tumour, a so-called lipoma, into a woman's breast. Prior to this, her real breast had been removed because she was suffering from breast cancer. Despite the use of the body's own fat, the blood supply remained inadequate. Experiments with materials such as ivory, bovine cartilage, wool or glass beads proved similarly fatal. Until the late 1950s, all possible uses were tried, such as paraffin injections (by Robert Gersuny), beeswax, or polyethylene, but without major success. In most cases, the use of such substances led to significant complications in the form of foreign body reactions, such as lipogranulomas. The first fixed implants were used in 1951. Ivalon sponges were initially well tolerated, but were immature in the long term. In 1961, two doctors from Houston (Texas) developed the first silicone implant on the initiative of the Dow Corning Company. In 1962 the first operation took place. In 1963 it was put on the market. 20 years later, this very company was sued by hundreds of women, as a fierce controversy had broken out in the USA that silicone implants were the cause of many autoimmune diseases and health problems. In 1992, silicone fillings were banned by the Food and Drug Administration (FDA) for cosmetic surgery in the US. After numerous studies and technical development of the implants, they were allowed again in 2006. They were never banned in Europe, but a quality seal has been in place since 2001 to ensure quality for patients. By 2011, ten million women had been operated on worldwide.

In organized crime, breast implants are used to transport drugs.

OP-Technique

During the operation, which is usually performed under general anaesthetic, a specialist (plastic, aesthetic and reconstructive surgeon) makes an incision in the skin, lifts the breast tissue and forms an implant pocket into which the breast implant can be inserted. The surgeon then either pushes the implant partially or completely under the pectoral muscle (submuscular implantation, especially in very thin women with little fat/glandular tissue) or places it under the mammary gland above the pectoral muscle (subglandular implantation, see picture), leaving the breast tissue itself largely untouched. A third option is to place the implant directly inside the muscle stocking and under the fascia layer covering the muscle (subfascial method, see picture). This method is more time-consuming, is considered more difficult and is only offered by a few surgeons.

The necessary skin incision, of which as little as possible should be visible after the operation, can be made in the newly formed underbust fold (inframammary approach), around or through the areola (transareolar approach), in the armpit (transaxillary approach) or, if saline solution is used, also in the navel. A technical specialty is the endoscopic breast augmentation through the axilla. It was already used in the early 1980s in Brazil by Ivo Pitanguy and has since been a routine operation for breast augmentation. Through a narrow incision in the natural axillary fold, a fine endoscopic instrument is inserted behind the pectoral muscle, which is initially bluntly and electrocauterically cut in the area of the muscle attachment in order to avoid deformation of the breast during arm movement. In this case, the magnification provided by the endoscopic image offers greater certainty that no sensitive nerves will be cut, but that the pocket behind the pectoral muscle will be shaped with millimetre precision. Both round and anatomical implants up to a size of 480 cm3 can be positioned safely. In the hands of the experienced surgeon, the technique is just as safe and precise as when the incision is made under or on the breast. As a rule, the operation time is shortened. This technique is not offered by all centres in Germany. So far, there is no evidence-based generally preferable method. The advantages and disadvantages of the 3 different access methods are mainly shaped against the background of the individual prerequisites and the experience of the respective surgeon with a method and are to be discussed in a consultation.

In subfascial implantation, the implant is inserted under the fascia.