Augmentation Mammaplasty with a New Cohesive Gel Prosthesis
Paolo Bogetti, M.D., Mario Boltri, M.D., Paolo Balocco, M.D., and Giada Spagnoli, M.D.
Turin, Italy
Abstract. We present our experience with augmentation mam-maplasty on 14 patients with a thin chest wall and poor sub-cutaneous tissue. Thanks to Polytech Silimed code 20675, anew anatomical prosthesis filled with “soft” cohesive gel, thelodging in a subglandular position was possible without anoma-lous salience in the upper pole, and a more natural mammaryprofile was achieved without capsular contracture, dislocation,or misplacement of the mammary implants.
The popularity of augmentation mammaplasty has in-creased over the last years thanks to improvements inoperating techniques and prosthesis quality. The devel-opment of surgical techniques has also enabled us toperform augmentation mammaplasty under local anaes-thesia with neurosedation in a day-hospital situation.This operation is recommended for patients whose breastsize does not match their body size and want to correctthe problem. Choosing the proper prosthesis is very im-portant to the surgeon who wants results that will meetthe patient’s expectations.
At the preliminary visit the surgeon will examinesome important breast features (size, shape, skin quality,nipple, and areola size), but he should also feel confidentabout choosing the most suitable prosthesis for eachcase, while trying to meet the patient’s requirements asmuch as possible [1]. Since the introduction of the Si-lastic gel implant by Cronin and Gerow in 1963 [2],several modifications have been made to prostheses inorder to achieve more and more satisfactory aestheticresults [3]. To guarantee a more natural mammary pro-file, with a good projection of the lower pole and slightfullness of the upper one, anatomical prostheses withhigh or low profile are now being used instead of roundones. In addition, the prosthesis surface has been
changed from smooth to microstructured and then to tex-tured in order to decrease capsular contracture [4,5]which gave the breast an unnatural shape and low mo-bility.
Considerable effort has also been devoted to makingprostheses as supple as the mammary gland by usingdifferent filling materials such as saline solution, siliconegel, hydrogel, and soybean oil [6]. At present, the mostwidely used implants contain a silicone gel. Dependingon the length of the polymer chain and the degree ofcross-linking, the silicone can be fluid, gel, or elastomer[7,8]. According to its cohesivity grade, the gel can beclassified as low cohesivity (round gel filled prostheses),high cohesivity (Tebbets prostheses), or medium cohe-sivity (prostheses with soft cohesive gel).
The approaches most commonly used for the insertionof a mammary prosthesis are incisions in the submam-mary fold, the periareolar, the transnippleareolar, thetransaxillary, and the abdomen [9]. Positioning of theimplants can be effected in the subglandular or submus-cular area.
Materials and Methods
The study is based on 14 patients, aged 23–30, with athin chest and poor subcutaneous tissue, who underwentan augmentation mammaplasty operation. The prosthe-ses used, Polytech Sylimed code 20675, which are newon the market, were anatomically shaped with a texturedsurface filled with “soft” cohesive silicone gel, volumesranged between 165 and 245 cc. Implants were posi-tioned in the subglandular area using the submammaryfold as an approach. The 4.5 cm long cut was made 1 cmabove the submammary fold, positioning one-quarter inthe middle and the remaining three-quarters on the otherside of an imaginary line connecting the midclavicularpoint to the submammary fold passing through the nipplecenter. Once the pectoralis major sheath has been found,the pocket is set up. The subglandular suprafascial un-
dermining, starting at an inferomedial level, goes side-ways along the pectoralis major muscular fibers, contin-ues upwards reaching the lateral edge of the pectoralismajor and its clavicular insertion and goes downwardsreturning to its starting point. Before inserting the pros-thesis, a drain is positioned and kept in place for 48 h,then the surgical cut is stitched layer by layer.
Results
All the patients who underwent surgery had a normalpostoperative period without hematomas or infections.
After 2 yr, the aesthetic result obtained was very satis-factory (Figs. 1–3). No prosthesis displacement, capsularcontracture, or altered sensitivity of the nipple-areolacomplex were noticed.
Discussion
In the course of augmentation mammaplasty operations,patients with a narrow, thin chest and scarce subcutane-ous tissue have been, up to now, candidates for prosthe-sis positioning in the submuscular plane [10]. In fact,owing to their particular thoracic cavity structure, insert-
Fig. 1. Polytech Silimed 20675, cc 165; 25-year-old patient before surgery (A, C, E) and after augmentation mammaplasty (B,D, F).
441P. Bogetti et al.
ing a prosthesis in the subglandular area may result inmammary profile alterations due to either cutaneous rip-pling, especially with round underfilled prostheses, or toan anomalous salience at the upper pole with a distinctdemarcation of the supramedial edge, as is the case withhigh cohesivity anatomical prostheses of the Tebbetstype. As a consequence, anatomical implants filled witha highly cross-linked silicone gel with a so-called“memory effect” (Polytech Silimed 20675) have beenproduced in order to guarantee a perfect preservation ofthe implant natural profile even in an upright positionwhile keeping a true-to-natural suppleness. Besides, thefilling gel specific memory has been designed to avoidany possible permanent or transitory deformation that the
standard cohesive gel prostheses may have because oftheir high grade of compactness.
From our experience, we can say that when soft co-hesive gel prostheses are used, implant positioning in thesubglandular area does not impair the final aesthetic re-sult. In fact, owing to the particular characteristics of thegel, the prosthesis shape does not show and, thanks to theplace where it is implanted, the breast takes on a verynatural and physiological shape: overall breast size andlower pole projection are increased while keeping thenatural proportional ratio with the lateral projection andavoiding any overfilling of the upper pole. Besides, asthe pectoralis major muscle does not have to be under-mined from the underlying planes or to be disconnected
Fig. 2. Polytech Silimed 20675, cc 185; 24-year-old patient (A, C, E) and after augmentation mammaplasty (B, D, F).
442 Mammaplasty with Cohesive Gel Prosthesis
at the inferomedial level, the operation is less traumaticfor the patient. When the pocket is set up (since anatomi-cal prostheses, unlike the round ones, have three spacedimensions that differ from each other), we prefer a sub-mammary surgical approach because we can then accu-rately make a lodging where any rotation or misplace-ment of the mammary implants can be prevented.
Finally, a small bulging marker, set inside in the triplebarrier of the implant in the 6 o’clock position, makes itmuch easier to check this lodging during the operation.
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Fig. 3. Polytech Silimed 20675, cc 245; 27-year-old patient (A, C, E) and after augmentation mammaplasty (B, D, F).
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