Breast Augmentation: An Expert Interview With Jennifer Walden, MD

Pippa Wysong


April 19, 2010

Editor's Note:

Breast augmentation is among the most common elective plastic surgery procedures in the United States. Medscape's Pippa Wysong spoke to Jennifer Walden, MD, who offered her thoughts on implant types, risks, and surgical approaches. Dr. Walden is a plastic and reconstructive surgeon based in New York City and is Clinical Instructor of Plastic Surgery at New York University Langone Medical Center. She is also certified by the American Board of Plastic Surgery (ABPS).

Medscape: Can you start by giving Medscape readers some background information about breast implants?

Dr. Walden: Breast augmentation is the most commonly performed cosmetic procedure among women in the United States. It really took off in November of 2006, after the FDA reapproved silicone gel breast implants.

Medscape: What are the main types of implants, and what is your impression of them?

Dr. Walden: Basically, what is available to us today are saline and silicone gel implants, smooth-wall and textured-wall implants. I prefer smooth-walled implants because they are more mobile in the submuscular position. In my opinion, textured implants don't confer much of an advantage with respect to capsular contracture when placed under the muscle. I feel that the smooth-wall implants are more natural-feeling and have a softer shell than textured implants.

Textured implants are commonly used because of the purported benefit in capsular contracture rates. However, when the implants are placed under the muscle, both types have similar capsular contracture rates. One problem with textured implants is that when they are submuscular, the shell can sometimes stick to surrounding tissues, getting stuck in a high position and resulting in an unnatural look.

Medscape: What are your thoughts on the shaped textured gel implants coming down the line?

Dr. Walden: Textured shaped gel implants are made to look more natural, with more fullness in the lower pole. There is the Allergan Style 410 implant, and the Mentor line of Contour Profile Gel implants. The rumor is that they will be approved by the FDA within the next year. They're currently available only in clinical trials, and many of the trials have closed.

Medscape: Were you involved in any of those clinical trials?

Dr. Walden: No. However, I'm involved in surveillance trials after FDA approval for breast implants, as are many plastic surgeons. After products are approved by the FDA, plastic surgeons can and should enroll patients in postmarket trials (Mentor's Post-Approval Study [PAS] and the Breast Implant Follow-up Study [BIFS]) that follow women with silicone gel implants long-term.

Medscape: Why should plastic surgeons sign up for these trials?

Dr. Walden: It's a good thing for plastic surgeons to enroll patients in such studies because they provide the FDA with information on breast implants and breast augmentation patients in a controlled fashion on a long-term basis.

Medscape: Do you have a preference for the type of fillers in implants?

Dr. Walden: I prefer silicone gel implants for most of my patients, mainly because they feel more like natural breast tissue. When placed under the muscle, they feel more moldable and less like a water balloon, which is what saline implants can feel like. Some of the problems with saline implants, such as rippling and spontaneous deflation, are not as much of a problem with silicone. If a saline implant leaks, the breast goes flat. But silicone ruptures can be silent.

Medscape: How do you check for silent ruptures?

Dr. Walden: Sometimes the clinical history suggests that the implant might have sustained enough force to rupture. However, it is much more likely that the rupture is silent and not detectable by clinical exam. The FDA recommends an MRI at 3 years postoperatively, then every 2 years after that. MRI is the best way to detect silent rupture; however, they can give you false positives. Plus, it can be tough to get patients to go for those MRIs -- they're expensive, and insurance might not cover them. It's up to surgeons to inform their patients about the recommendations so they can make informed decisions. The FDA wants long-term follow-up on rupture rates, as do the implant manufacturers and surgeons.

Medscape: You mentioned ”under-the-muscle” implantation. Is that the way to go?

Dr. Walden: That's what I prefer, though in special cases, such as in bodybuilders, I may recommend under the gland. However, I haven't seen a female bodybuilder yet. With submuscular placement, or the dual-plane approach, you place the implant under the breast muscle so that the top two-thirds is covered by muscle and the bottom one third by the breast gland. That helps reshape the breast in cases of early ptosis or tuberous breast deformity and gives the implant muscle coverage.

I don't do subglandular augmentations because I don't think the appearance is as good. There are also issues with implant palpability, visibility, and capsular contracture. I see patients coming in for second opinions after having surgery elsewhere. They are seeking revision because of advanced capsular contractures and implant malposition with subglandular placement. Some studies suggest that capsular contracture rates are lower with submuscular placement. However, for surgeons, subglandular augmentation is quick and easy to do.

Medscape: In general, what are some challenges with patients of different body sizes and weights?

Dr. Walden: The most challenging patients are those with very small breast bases and tight tissues -- a tight muscular pocket, very tight skin. This is common in people of Asian descent. Dissection of the pocket and placement of the implant through a small incision becomes more technically difficult.

Medscape: Which incisions do you use, and when?

Dr. Walden: The inframammary crease is what I use about 60% of the time. I prefer that for women with well-developed inframammary folds or hints of ptosis. I consider that the gold standard. In about 30% of my cases, I use a periareolar incision -- that's for people with ill-defined inframammary folds, a distinct border between the areolar skin and breast skin, and larger areolae.

I use transaxillary about 10% of the time, usually for people who strongly prefer it. It's ideal in women with short breast heights without a lot of ptosis, without chest wall abnormalities, and with a short torso. If the patient is lean and tall with a long breast height, it is technically harder to perform because you're going through the armpit, looking in with an endoscope. Then there are certain chest wall deformities, such as pectus excavatum. I would use the inframammary crease for these patients. Cases of asymmetry are also tricky.

The anatomy and desire of each patient dictate which incision I'll use. The implant I use can also influence the decision.

Medscape: Are there any difficulties regarding patients and expectations?

Dr. Walden: Most people are realistic about breast augmentation. However, there are some cases, such as women who underwent multiple previous breast surgeries and have problems, such as capsular contracture, where she wants to look like new again. Some patients want to look the way they did when they first had an augmentation. People who have been operated on elsewhere can be tough, and may require extra time in the operating room.

Medscape: Do you have any tips for managing expectations?

Dr. Walden: Managing expectations is crucial, especially in patients who have abnormalities, such as tuberous breast deformity, constricted base deformity, or massive asymmetry. Some patients with asymmetry might think that you can somehow make them look like a 20-year-old with no asymmetry. Results won't be perfect because there are some difficult anatomical issues, although patients will have a marked improvement. It's hugely important to discuss expectations preoperatively.

The preoperative analysis is very important. It uses objective data, such as base diameter, pinch thickness of the tissues, and a numeric system, to help grade the breast and pick out the breast implant size. This is important for meeting patient expectations for size so that both the patient and the surgeon are happy.

The other thing that's vital is an informed consent process. I do a lengthy informed consent based on the Tebbetts consent forms that addresses expectations, preoperative tissue qualities, and asymmetry -- factors you cannot control as a surgeon -- and the trade-offs associated with breast augmentation. Patients need to understand that a breast implant is not a lifetime device. Rather, it requires monitoring, it may need to be replaced, and most patients will need additional surgery later in their lifetime.

Medscape: What are your thoughts on fat injections for breast augmentation?

Dr. Walden: That's something in the pipeline. The downside of fat injections is that they could be temporary. They could also produce lumps, bumps, calcifications, fat necrosis, and problems with mammography results. There are no controlled long-term clinical trials showing what the 5- or 15-year outcome is. It will be difficult to explain to patients that fat injections could look like breast cancer on mammograms, leading to biopsies, confusion, and angst.

However, fat injections help with cosmetic results in breast reconstruction and are good for implant-related contour abnormalities. They are smaller parcels of fat, and people who had breast cancer and reconstruction get monitored more. I think injecting your average, healthy 21-year-old woman with large amounts of nonvascularized fat into her breast could lead to problems. She's not going to get the monitoring she may need. We're still learning about this -- stay tuned!