The Clinical Problem (Fig. 25.1)
Hypomastia is usually a developmental issue but may also be seen after pregnancy, breastfeeding, or major weight loss. It is well known how negatively the size, shape, and symmetry of a woman’s breast may affect her mental and physical well-being
Women with severe developmental hypomastia should not expect significant breast augmentation but aim to have more normal-looking breasts. This more conservative approach is intended to improve their negative self-image perception and their fear of very noticeable changes.
In contrast, women with involutional hypomastia are in their 30s, may have already breast-fed, and are disappointed with the loss of skin elasticity volume and consistency of residual breast tissue. Their aesthetic perception is linked to previous size or to the increased breast size seen in pregnancy. It is not uncommon to see a patient who carries a picture of her breastfeeding period showing this as the desired size.
Surgical Preparation and Technique
Management and Treatment Options
Smooth, round, silicone elastomer-containing silicone gel implants have been available since the beginning of modern breast augmentation surgery, when they were introduced in 1962 by Cronin and Gerow, but capsular contracture has always been of greatest concern in the years following. To lower capsular contracture rates, a coat of polyurethane foam was first applied to the implant’s surfaces in 1969 by Ashley”; since then, it has been reported as the most successful device to avoid periprosthetic capsular contracture.
Later on, in an attempt to reproduce the surface appearance of polvurethane, textured implants were developed. However, polyurethane implants, as compared to smooth and textured implants, remain the best option for the treatment of recalcitrant capsular contracture, although thicker shells and a more cohesive gel can also contribute to lowering the rate of this complication.
With the biodimensional concept, cohesive gel stable form implants, with different shapes and projections, became available to assist a wide spectrum of anatomic variations. Interestingly, Ashley’s first polyurethane implants were an anatomic teardrop shape. Round implants, containing less cohesive gel and placed in submuscular pockets, will assume a teardrop shape when the patient is standing.
A round implant has, on average, 15% more gel than an anatomic one with the same base and projection, making it heavier and leading to greater distention of the lower pole of the breast. This bottoming out is associated with an early relapse of breast ptosis after mastopexy with breast augmentation or with implant-induced breast ptosis.
As a general rule, the ideal implant should be as light as possible. Its volume distribution should be customized to individual anatomic variants and the patient’s preference.
Assessment of Problem: Anatomic Description
The breast parenchymal base width may not be adequate to hide the implant’s edges perfectly. Also, young patients may have very firm skin, which limits the available projection of the breast mound.
It must be stressed to the patient that selection of the ideal implant is based on biodimensional analysis and not on its volume, because obviously the same size of implant will look different in different body types. To customize breast augmenta-tion, the width and height of the parenchyma footplate, the…