5:1 STRUCTURE OF THE BREAST & COSMETIC PROBLEMS OF BREAST:

Female breast occupies space from 2nd rib to 6th rib. Pectoralis and serratus amterior muscle from the base for breast gland. Nipple and areola are pigmented. Nipple is surrounded by areola. Nerves ending from the fourth rib space provide sensation to nipples. Areola enlarges in size after the pregnancy. 10 to 12 lobes are present in a glandular tissue of each gland. Each gland has a separate duct which opens on the surface of nipple. Suspensary ligament connect gland tissue to the skin. Suspensory ligament and fibrous tissue supports glandular tissues. Fat tissue surrounds the breast superficially and peripherally. Proportions of all these three compartment varies with the status of nutrition, age, pregnancy, menopause etc.

Some women have larger breast in proportion with their figure. These breasts may cause other problems like pain in back. Reduction in size and shape of too large breasts can be done. Some women have breasts which are drooped due to aging or breast feeding or weight changes. They can be benefited by non-surgical breast lift or surgical breast lift. Some women have smaller breasts which can be increased in size by putting breast implants. Some women have undergone removal of breast due to disease in it. These women can have breast after putting the breast implant.

5.2 BREAST IMPLANT SURGERY/ AUGMENTATION OF THE BREAST

Some women have smaller sized breast. They like to increase size of their breast. Some want proportionately bigger, better and elevated breasts. Some have drooping of the breasts due to weight loss or aging. So, they want to augment breast. Some may have bilaterally uneven size of breast. They want to increase size of smaller breast & reduction of larger breasts upto proper size. Some times the breast may be congenitally absent. It can be formed. If a female patient has flattened chest, optimum size of implant help a lot to improve feminine appearance of such women. Surgeon asks, how much bigger size of breast she wants? The need of extent of extra size depends upon the amount of breast tissue, shape of chest wall and weight.

Breast surgery for improvement of appearance:

There are three varieties of incisions in breast surgery. Any one type of them can be used. a) Periareolar incision: It is given around the areola. It is most concealed. But it may cause more inability to breast feeding. b) Inframammory incision: This incision is given in breast fold. It does not hamper breast feeding. It is less concealed than periareolar incision. c) Axillary incision: Axillary incision is given. It is least concealed incision and do not cause problem in breast feeding. d) Endoscopic or umbilical incision: It is not yet fully recommended. Stop smoking and tobacco consumption in any form few days prior to surgery. It slows healing process. Take something to relax or pass the time like magazine, walkman.

Breast enlargement: (Augmentation mammoplasty)

To enhance size of the breast by using implants, surgery requires 1-2 hours of time. It can be done under local or general anaesthesia.

Side effects:
Temporary swelling, soreness, bruising, change in nipple sensation.

Risks:
Lack of implant permanence of surgical removal and replacement may be required. Sometimes deflation of implant may be required. There may be an increase or decrease in sensation. Mammography requires a special technique.
Patient is back to work in few days.

Local anaesthesia Vs general anaesthesia: -

Local anaesthesia is safer, cheaper and keeps the individual mobile even during surgery. In anxious person or person having emotional fear are given sedation. Slight pain of injection is felt during injecting local anaesthesia and later on no pain is felt. General anaesthesia is less commonly used because it is not without safety.

Importance of mammogram:

In all cases of breast reduction, mammograms are done preoperatively to rule out existing disease like cancer in the breast and to establish latest baseline mammogram which is useful to compare mammogram done in future In the same patient 4-6 month after reduction of breast, mammogram is repeated to re-establish new baseline mammograms. After traditional surgical reduction of the breast, patient may develop postoperative inflammatory nodules and lipid filled pseudocyst. Mammogram shows calcifications and other changes. These complications are rare if breast reduction is done by liposuction. Calcification is also seen in operated breast. Calcification caused by cancer and that by surgery differs in appearance.

Deciding breast volume: Breast volume is measured by immersing breast in a beaker filled upto brim with lukewarm water. The amount of water required to refill the same beak upto brim is measured. The average of two reading is taken. This measurement is necessary to decide volume of fat to be removed. It is also helpful to decide difference in volume of two breasts when these are of unequal size. Fat injection into breasts: Fat from one part of body can be implanted into the breast to augment. Sometimes it may cause fat necrosis or liponecrotic cyst.

To augment breast, what kind of implants are used? Two types of implants are available. These are saline breast implant and silicon implants. Each type has its own advantages and disadvantages. Where is the implant placed? Implant may be placed over the muscles or under the muscle. If implant is put over the muscle, it provides slightly fuller result on the top. If implant is put under the muscle, it provides somewhat more natural effect. How the breast will appear after putting the implant? Let the doctor know what do you expect so that efforts are done to provide best results as per your expectation.

How much is risk in breast augmentation?

Like any other surgery, there is a risk of infection, bleeding, scarring etc. Thus, risk is not unusual.

In case of saline implant, what happens if it bursts? Generally, implant does not rupture. But if at all, ruptures, saline is absorbed like drinking glass of water. Chest of that side will be deflated. How much is life of the implant? There is no upper limit of duration of lasting the implant. It depends on how much your body adjusts with it immunologically and how much care you take. Generally it persists for two decades. When can I become fit to join the work? One can do light job after four days. Stamina to tolerate discomfort varies from person to person. When will I able to drive? Avoid driving immediately after discharge from hospital. After 4 to 5 days, you will able to drive a car. For how much duration will I be in hospital? You will be discharged after 6 to 10 hours of rest. When will I be able to resume my usual activities? One needs rest to muscles of chest and arm. So, do not lift weight more than five Kg for about four weeks. Avoid playing like tennis for a month. Do not carry children with the help of upper arm. After breast implant, will I be able to breast feed? Yes, it is possible to breast feed.

Does ‘Breast implants delay the diagnosis of breast cancer’?

No, it is a misconcept. It is always better to do mammography before breast implant surgery.

How much size of implant should I select?

It depends on your present size, body proportion, body strength. It also depends on the purpose of why you want to increase size of breast. It is decided in consultation with doctor.

For many patients, they are not knowing how much augmentation fits her proportion. So, later on 32% patients may choose to undergo reoperation for the replacement by more robust size.

5: 3 REDUCTION MAMMOPLASTY: (BREAST REDUCTION)

It limits athletic activity, routine physical activities. Excess large breasts can cause pain in back, neck and shoulder. She faces problem of cosmetically undesirable appearances. She may not find bra that fits comfortable. Clothes do not fit well and it may cause chronic pain. Due to larger breasts, skin of lower part of the breast rubs with the skin beneath the breasts. It predisposes the fungal infection. Huge breasts affect curvature of the spine and spinal arthritis.

When women need to undergo a breasts reduction operation?

If breasts are too large in proportion to your body frame, or if large breasts cause back pain or neck pain or shoulder pain, or physical discomfort, if heavy breast or pendulous breast with nipple are pointing downwards or if one breast is larger than the other, if larger breasts cause restricted physical activities or if women is self conscious about the size of the breast, if larger breast causes skin irritation beneath the breast, breast reduction surgery is done.

Advantages of breast reduction:

After breast reduction, breast will be more proportional to the rest of body and clothes fits better. Every year thousands of women undergo successful breasts reduction surgery and are pleased with the results. This surgery makes breasts optimum in size and firm in consistency. So, such women find greater enjoyment and can easily do physical activity, sports and routine activities. It makes dramatic changes in appearance. So, Women feel more comforts in their clothing. Their confidence about good appearance and self attraction boosts.

Consultation:

Doctor examines breasts for size, shape, placement of nipple. He also assesses the availability of the skin of the breast. He asks the woman what does she expect. Which technique is used to reduce breast? There are variations to design the breast after reduction. Taking into account patient’s desire about new size, shape, extent of reduction, type of technique is chosen.

What types of incisions are used ?

Following three types of incisions are used:

a) Horizontally in natural curve of the breast crease beneath the skin b) Around the areola. c) Vertically from the bottom edge of the areola to the crease underneath the breast. Excess breast tissue, fat and skin is removed. The nipple and areola is moved to higher position.

Risks in surgery: Risks are not more than any other surgery. Complications are rare.
Surgery: Breast reduction surgery is done under general anaesthesia. One needs to stay in hospital for 24 to 48 hours.

Precautions after surgery:

Swelling and bruising subsides in 3 to 4 days. Take enough rest. Avoid lifting, bending and straining for about two weeks. Supporter bra should be worn for two weeks. Avoid strenuous work after two to three weeks. In four weeks, most of usual activities can be restarted. Incisions fade over the time but will remain visible to some extent. These incisions are concealed easily by minimum clothing and like low cut neckline. Women take some time to adjust to changed appearance.

Excess dense tissue and fibrocystic diseases in breast: Some women have breasts which have more proportion of glandular tissue and less fatty tissue. Some women have fibrocystic disease of breasts. In both of these women, liposuction is not helpful. Those who want more than 50% reduction of breasts size and those who have excess glandular tissue and those who have fibrocystic disease should undergo traditional surgical breast reduction in which excess skin and breast tissue is excised. These women are happier in spite of unsightly scar.

Lump in breasts:

These women are evaluated with mammography. Those who have significant family history of breast cancer are very carefully considered. Palpable lump may develop after liposuction which disappears after few months.

Milk production after breast reduction: After reduction of breasts by liposuction, there is reasonable chance that she will be able to breast feel. In traditional surgical reduction of the breast, the breast tissue and ducts are damaged and are blocked by excess scar tissue. It prevents milk production and breast-feeding.

5:4 BREAST LIFT / MASTOPEXY:

NON-SURGICAL & SURGICAL METHODS

Many women feel to undergo breast lift & boost their confidence.

Lifting the breast: Some women develop sagging or ptotic breast tissue after child birth. The attractive shape of the breast is reduced due to gravity, weight loss of the body, pregnancy and breast feeding. So, firmness of the breast is reduced. Such breasts needs the breast lift procedures. It make them firm so that breast will achieve more youthful contour. In this procedure, nipple and areola are elevated to new positions.

Breast can be lifted up by two methods:

1. Without surgery
2. With surgery

Breast lift procedure without surgery is helpful in mild to moderate cases of sagging or ptosis or pendulous breast.

Non-surgical breast lift can be done with ISOGIE equipment available at our centre. Woman needs to visit our centre twice in a week for multiple sittings to achieve effect of breast lift.

In surgical breast lift, incision is placed around the areola. (the pigmented skin around the nipple) sometimes it may be placed below the nipple and within the fold under the breast.

If the volume of breast is reduced or appears less, simultaneously breast implant can be inserted. It elevates position of the nipple.

Women should know the risk of breast surgery and keep realistic expectation. Do not expect perfection. Keep in mind that reshape of your breast improve your appearance and confidence but it will not reshape your life. To reshape your life, you need to take own efforts.

To raise and reshape sagging breast, breast-lift surgery procedure is done. Breast tissues and nipples are repositioned.

Operative time: 1-3 hours

Anesthesia: Can be done under local or general anesthesia.

Anchor shaped incision is given around area which extends downwards and follows the natural curve of the crease beneath the breasts. Excess glandular tissue, fat and skin is removed. So, nipple and areola moves to new position. The skin is stitched around and down the areola. Shaping the new contour of the breast. (Simultaneously liposuction may be done to remove excess fat from the armpit area so that results are better.)

Bruising and swelling disappears in first few weeks. Pain may be felt for about 1-2 weeks. One can go back to work and social activities in 10 to 14 days. Avoid heavy lifting or pushing for 3-4 weeks.

Side effects: Temporary swelling, pain, bruising, dry breasts, permanent scar. Occasionally, bleeding, infection, soreness of nipple may be felt for some period. Possible loss of feeling in nipples or breasts, permanent scar, possible difficulty in breast feeding.

Risks:

All surgeries carry some uncertainty and risk. Complications are infrequent and minor. Skin loss, infection, thicker scar, changes in sensation, uneven positional nipples.

Recovery:

fit to join work in one to two weeks. Strenuous work in one month.

Results of surgery in general:

Results of surgery depends on skill of surgeon, healing ability of the patients, extent of disease, duration of disease, anatomical variations and any complications developed. Results are permanent. Some factor retards proper healing of the wound e.g. habit of tobacco product, immunity status, anaemia, poor nutrition, past and present medication and treatments.

Avoid certain drugs: e.g. a) Antidepressants-Ascendin, Norpramin, Nardil, b) Anticancer drugs: Fluorouracil, methotrexate, c) Diuretics: Lasix, diamox, d) Antimicrobials like tetracycline, ciprofloxacin, nalidixic acid.

Breast sensitive to weight changes, pregnancy and hormonal shifts. For breast lift, 50 units of botox is used to inject in pectoralis minor or part of pectoralis major.

5:5 REDUCTION OF BREAST WITHOUT INCISION

BREAST LIPOSUCTION

Tumescent liposuction of the female breasts: Liposuction can reduce female breasts by 50% in size depending upon the percentage of fat tissue. It also lifts the breast to significant degree. Reduction in weight of breasts helps to the natural elastic tissue to contract and produce elevation. Thus, liposuction makes breasts smaller and elevated but does not change the shape of the breast. Thus, smaller version of the breasts is produced without surgical scars.

Procedure of Liposuction to reduce breast:

Local anaesthetic solution is infiltrated with thinnest needle to minimize pain. Liposuction is done with microcanals of 1.5mm diameter to 2.7 mm diameter. Then, absorbent pads are placed around the breast. Then, these are fixed with elastic crepe adhesive tape. Breast compression garments are worn to hold the pads in place. The pressure of these garments should be optimum. If compression is less, there is risk of bleeding and if compression is too tight there is experience of pain and difficulty in breathing. Pressure of compression should be adjustable. During initial 15 hours of post liposuction period maximum compression is required to limit post operative haematoma and to reduce bruising. After 15 to 18 hours drainage is reduced and so compression is reduced to moderate level for 48 hours. Then, compression is kept at comfortable level to support the tissue. Very rarely, canula or needle may puncture the lining over the lungs which may cause pneumothorax. Air leaks inside the chest cavity and which may impair breathing. Small scars of liposuction of 1 millimeter size disappear within few months. In patient of dark skin, post inflammatory hyper pigmentation develops after surgery which fades away after 2 months. Thus, recovery is rapid, with virtually no scars. Patient can return to work and routine activities within 2-3 days after the surgery.

Who should not undergo this liposuction procedure for breast reduction?

Women who have more glandular tissue than fat (e.g. thin younger women and women who have unusually larger breasts, are not good candidate for liposuction of the breasts. Those who need more than 50 % reduction in size and elevation of breasts, traditional surgical breasts reduction is done. Those who have lump in breasts, excessively dense tissue in breast and family history of cancer of breasts, this procedure is not done.

Unrealistic expectations:

Liposuction is done under local anaesthesia, incision scars disappears after few months. So, there is virtually no scarring. Patient after surgery can quickly return to usual activities in 2-3 days. Reduction in size is indirect proportion of volume of fat removed. There is a minimal risk in this procedure. Those, who have children should not expect that they would have perfect breasts of virgin again. This is over expectation.

Who is considered good candidate for reduction of breast by liposuction?

Women who have passed through menopause contain larger proportion of fat then as compared to teenagers. So, they are good candidates for breast reduction by liposuction. Candidate should have realistic expectations. Overweight young woman (i.e. before menopause) are also good candidate if she wants less than 50% reduction of breast. The proportion of fat in the can be determined by mammograms. Thin young women contain more glandular tissue and least fat. So, they are not candidate for breast reduction by liposuction method. Women who have unrealistic expectation (very perfect breast of a virgin) are not good candidates for breast reduction by this method.

5:6 Improvement of Pendulous breasts / empty breasts:

Excessive pendulous breasts contain only small amount of fat & excess amount of skin area. These sag down & drop down excessively. In sagging or drooping breasts, tissue is less. Such empty breasts and pendulous breasts can be corrected by excision of the skin and insertion of breast implants.

5:7 Reduction of size of areola:

Pigmented part of skin around the nipple is called as areola. Areola can be of excess size due to genetic predisposition, stretching due to extra size of breast, or breast implants. After breast reduction, in comparison to new size of breasts, areola appears bigger. So, it needs reduction. Excess skin of areola can be removed with good cosmetic result. To reduce larger than desired size of areola incision is given around the areola. Excess areola tissue is removed. A pedicle is left. Internal purse string sutures are taken to prevent stretching of areola and the scar. Incision is sutured. The scar of such suture may not flatten in time. Significant volume removal of tissue is contraindicated with the periareolar incision. New areola is puffy, barging. Swelling, pain and bruising is minimal. One may join the light job after 2-3 days.

5.8 Breast nipple surgery:
2% women have inverted nipple or shy nipple. ‘Densely inverted nipple’ prevents breast feeding. If natural secretions are trapped in such nipples, irritations and infection develops. Shy nipple is a nipple which can be drawn out by sexual stimulation or breast feeding.

Inverted nipple:

Inverted nipple causes breast feeding problem. It reduces self esteem. Inverted nipple may appear flat or slit like depression or patient resumes usual activities within 5 days.

Nipple reduction:

Every year, many women reshape their ugly nipple or over sized nipples. Some women’s nipples are hanging down or folded. These can be corrected. This is minor surgery done under local anaesthesia. No admission is required.

5:9 Enlarged male breasts:

(gynecomastia) In males, fat is generally deposited in abdomen, flanks, cheeks, chin and jowls. Deposition of fat in breast is rare. So, usually males do not have breast enlargement. In 75% newborn, due to maternal oestrogen hormone, breast may enlarge temporarily. In puberty, 60 % of normal boys have temporary enlargement of the breast for few months.

Normal male breast:

Typical male breast tissue is localized, small lump immediately under nipple. This areas is more firm in comparison to surrounding fatty tissue. The tissue contains fibrous glandular tissue and fat (adipose) tissue. One may come to know about amount of each tissue by doing routine mammogram investigations.

What is gynaecomastia?

Enlargement of breast in males is called gynaecomastia. It may be due to glandular tissue or fat deposition or both simultaneously. In most of the men, having gynaecomastia, have large amount of fat tissue and little amount of glandular tissue.
Thus, male breast enlargement is of two types: Pseudogynaecomastia and true gynaecomastia.

Pseudo-gynaecomastia:
Enlargement of breast with normal amount of glandular tissue but excess amount of fat tissue is called pseudo gynaecomastia. It is more common cause of breast enlargement. Obese younger men and elderly males are more likely to have such gynaecomastia.

True gynaecomastia: -
It is caused by excessive glandular breast tissue. It is not common in males. It develops due to failure of testicles to produce sufficient testosterone hormone. It may also develop due to alcoholism, medication, HIV infection, renal failure, treated with haemodialysis, adrenal corticosteroid hormone, secreting tumours and certain cancers of testes. Only one side breast enlargement may suggest possibility of breast tumour. Such patient needs to undergo mammography. Drugs like amphetamines, anabolic steroids, androgens, antiandrogens ( cypoterone), anticancer drugs like (e.g. cytotoxic), cimetidine, Lusulfan (myleran), clomiphene, amodarone (cardorone), domeperidone, diazepam, digitalis, oestrogens, isoniazid, kotaconazole, methyldopa, marijuana, nifedipine, phenytoin (dilantin), reserpine, tricyclic antidepressants, spironolactone, vincrystine may cause gynaecomastia. Sometime reverse is also seen. These tissues can be removed with the help of microcanulas, without damaging muscle tissue. Rarely very dense glandular tissue requires surgery.

With liposuction canular glandular tissue is difficult to remove but fat tissue can easily removed. If this tissue cannot be sucked by microcanula, (size gauze 12 to 16 ( i.e. 2.2 mm to 1.2 mm) larger canula of size 4 mm are used. These canulas have length of 5cm. Like liposuction, this procedure is done under local anaesthesia after injecting tumescent anaesthesia. After the procedure, these small holes are allowed to remain open to drain away blood tinged tumescent anaesthesia solution. These holes heal without obvious scar. In most of the patient, more than 50% size is reduced. If patient has minimal amount of excess fat tissue, the improvement will not be more than 30%. Some patients have higher expectations which may be unrealistic because more removal of tissue leads to uneven results, skin irregularities, excessive scars, asymmetry. Using microcanulas minimizes these problems.

Breast reconstruction:
By patients own tissue: It is reconstructed from long stomach muscle (Rectus abdominis) which runs from the sternum and rib cage to the pubic bone. By preserving its blood supply muscle is reworked into a breast mound. Other muscles like latisimus dorsi can also be used. Nipple is reconstructed and tattoing on the areola is done. Patients who are obese, or who have high blood pressure or who consume tobacco product in any form may be asked to wait before giving appointment and until they become fit for surgery.

Use of tissue expander:
A balloon like device called tissue expander is placed under the chest muscle. It is slowly filled with saline to create space in the chest for a breast implant. If this expander is intended to remain in the patient’s chest, it is left as it is, others are removed and replaced by a more permanent implant filled with saline.
Voluntary choosing to undergo cosmetic surgery requires courage.

Tissue expansion:
To give extra skin, tissue expansion technique is used. It stretches the adjacent tissue and helps to create space for implant. Tissue expander is balloon like device. It is a placed under the skin near the area to be repaired and then gradually filled with saline to stretch the tissue. Tissue expander helps the body to grow near perfect match of skin colour, sensation and texture. Scars are less apparent.