The choice of breast prosthesis, or how to choose the right prosthesis for each patient and why.
I compare the final result of a breast augmentation through the placement of prostheses with the final result of a culinary dish: with the same ingredients each cook will prepare a different dish. A little more cooking, a little more frying, a sprig of bay leaf? small differences that make the difference. There will be delicious, sophisticated, tasty and even unpalatable (for example, if one of the seasonings or the whole dish is burnt).
In the same way, each surgeon, with the same patient, will obtain a different result… Therein lie the nuances, taste, sensitivity, surgical capacity, knowledge of the technique to be used in each case and, most especially, the type of response in capsule formation and healing.
Faced with the same patient, each surgeon can choose a certain volume, one or another type of prosthesis, an access route, a location for placement … however, each of these choices are not so important in isolation but what is essential is their combination, that the choice and combination of all these factors give the desired result. Our goal is to achieve natural breasts, both in shape, size, symmetry and mobility.
One of the concerns that most accompany patients who come to our office is what type of prosthesis is going to put. The question does not refer specifically to the brand of the prosthesis, which also refers to it, but to all the other characteristics that can vary in them. We will now list and comment on some of the variables of the prostheses.
Volume
It is very variable and normally ranges between 125cc and 450cc. The choice of the size of the prosthesis is very difficult. In principle there is no size that suits but the desire to achieve a shape that is related to the image of femininity that each patient has. The method we use to define the size of the prosthesis is to place prostheses of various volumes in a bra without padding until we find the one that best suits you.
Content
Currently, prostheses filled with cohesive silicone gel and physiological serum are used. The choice is usually made by the surgeon and responds more to the experience you have with each of them. We prefer to use silicone prostheses filled with cohesive gel. They have the advantage over those of silicone oil that if the solid membrane wears or breaks, its content does not come out but remains cohesive and does not migrate; moreover, if we puncture a prosthesis and compress it, a bubble will come out and will be completely reinserted when we stop doing it. For this reason it is no longer necessary to change the prosthesis after 8 or 10 years and annual check-ups are simply advisable to verify its integrity. This can be accurately assessed by magnetic resonance imaging. On the other hand, these prostheses are more natural to the touch than those made of serum.
The serum ones have the advantage of the minimum incision needed to insert them since they are placed deflated and filled once inside the breast and, in addition, if the bag containing the serum is worn out, its content is reabsorbed without problems by the organism. However, they have their disadvantages, among which we can highlight the possibility of loss of content through the valve (they can deflate, that is, lose part of their content, one or both prostheses), the greater hardness and weight (they are harder to the touch) and, sometimes, they cause certain thermal sensations (they can give the sensation of local cold because they heat up more slowly than the body) or sound (water movement).
There are other prostheses filled with methyl cellulose, but they are not used in Spain and we do not use them.
Lining
It is the membrane that forms the bag inside which the gel or serum content is kept. It can be made of silicone sheets, Polyurethane and Titanium (its possible use is being investigated).
Surface
This is another point of controversy. The surface of the prosthesis can be smooth or rough. At present, approximately 30% of Spanish plastic surgeons place smooth prostheses under the muscle. While practically all of us place rough prostheses above the muscle, that is to say, below the gland or the aponeurosis of the pectoral muscle. The reason for each choice has to be reasoned and, logically, justified by research that demonstrates or corroborates the choice.
Historically, the evolution was as follows: The first silicone prostheses used were smooth-surfaced and were placed directly under the gland with a high rate of capsular contracture. To remedy this, it was investigated and it turned out that the roughened prostheses caused capsular contracture in smaller numbers and of lesser intensity (with the prostheses directly under the gland). Later the position of the prostheses was reconsidered and it was seen that the submuscular position was more adequate since the implants would not be in contact with the gland and, therefore, with the frequently contaminated lactiferous ducts (contamination is one of the possible causes of capsular contracture). Logically, and always avoiding capsular contracture, it was thought that under the muscle and with rough prostheses the feared capsular contracture would practically disappear. This was not exactly the case, although it did decrease considerably in number and intensity.
In this position (submuscular) and with this type of prosthesis (rough) some inconveniences began to appear: on the one hand, if the prostheses ascended it was difficult to descend them again (being rough they remain adhered) and, on the other hand, the prostheses had different response depending on whether they were massaged or not and, of course, the moment in which they began to be massaged. If they are not massaged the prostheses remain more or less firm, they project the gland and the result can be wonderful, unless you have little gland, in this case they will remain firm, of course, but also immobile: on the beach, lying down, they typically look like breasts with prostheses. If they have a gland, the thing improves, since the gland is lateralized and gives a more natural appearance.
If we want to get the prostheses to move in the pocket we have created, then it is necessary to mobilize the prostheses as soon as possible. In this case the roughness of the prosthesis stimulates the body to produce an external capsule (the normal one) and another capsule that directly surrounds the rough surface of the prosthesis; this means that the body is transforming the rough prosthesis into one with a smooth surface. To avoid this added work, we prefer to place smooth-surfaced prostheses under the muscle.
However, there are some situations in which we prefer to place rough prostheses in this location (submuscular): when the patient presents thoracic deformities that can favor the displacement of the prostheses (pectum excavatum, pectum carinatum, thoracic asymmetries…). In these cases the adhesion of the prostheses avoids unwanted displacement of the prostheses.