Features
Alternative breast augmentation
PART ONE
Rather than simply choose manufactured breast implants, women have non-surgical
alternatives available for breast augmentation. Mr Vik Vijh discusses the pros and cons
The demand for breast augmentation has increased exponentially since the introduction of silicone implants by Thomas Cronin and Frank Gerow. According to the American Society of Plastic Surgeons (ASPS), the insertion of breast implants remains the most commonly performed cosmetic surgical procedure in the US, with 355,671 procedures performed in 2008.
While surgical techniques and the quality of mammary prostheses have improved in recent years, patients are still confronted with significant potential complications, with a revision rate between 2-10% per patient in fourth generation implants. The dissatisfaction with these complications has driven the pursuit of new and improved techniques.
Over the last 10 years, cosmetic surgery has seen explosive growth in minimally invasive and non-surgical procedures. For most patients the reasons for this are simple: there is less downtime; minimal pain; and it is initially cheaper and marketed as "no or little risk."
Results are temporary so if the outcome is less than satisfactory, it will correct itself. Minimally invasive breast augmentations offer a reversible insight into what a traditional augmentation can achieve.
Herbal treatments
Many hormonally active herbs are advocated for breast enlargement. Hops contain 8-prenylnaringenin, which is a phytoestrogen—a weak plant-derived oestrogen structurally similar to human oestrogen. Phytoestrogens are thought to stimulate oestrogen receptors present in breast tissue and can cause increased tissue formation.
Other dietary supplements contain substrate for fusarium—a fungus which produces zearalenone (ZEA), a potent oestrogen that acts in the same manner as phytoestrogens. As well as potential breast growth, several studies have indicated that ZEA can provoke oestrogen-dependent breast cancer. But the evidence is far from conclusive and other papers have shown that ZEA has a protective effect against breast cancer.
Homeopathic remedies have also been advocated for breast enlargement. Conium maculatum, also known as poison hemlock, is a herb which grows up to nine feet high and resembles a carrot plant. It is poisonous and was historically used as a state poison by the ancient Greeks. It has many alleged benefits including improvement of withered, flabby or painful breasts, and breast cancer. It also has analgesic properties.
At high doses death can occur as a result of respiratory arrest from paralysis of the respiratory muscles and central depression. There is no evidence at varying potencies of any benefit in breast cancer or breast enlargement.
There is no evidence that breast hormone or homeopathic supplements have any effect on breast growth. Supplements are also potentially harmful and can increase the risk of hormonally-dependent cancers such as breast and ovarian cancer. The use of these products should be discouraged in view of these long term safety concerns.
A variety of injectable treatments have been used to temporarily or permanently augment breast volume. These have the advantage of being minimally invasive, with no scarring and less downtime than traditional procedures. They are, however, costly and have potential side effects that are not insignificant.
Macrolane is a commonly used filler for breast augmentation. It consists of a non-animal stabilised hyaluronic acid derived from bacterial fermentation. The stabilisation is an essential step to reduce reabsorption, while resembling the body’s own hyaluronic acid and minimising the risk of tissue reaction.
It is a temporary filler, metabolised by the body over approximately nine months. Initial treatment costs around £2800 with an annual top-up cost of £1400, so long-term treatment is more expensive than conventional implant-based breast augmentation. Macrolane is intended for patients seeking small to moderate enlargement and breast contouring. It is not suitable for patients with ptosis of the breasts, pronounced skin laxity, or those seeking large volume augmentations.
Assessment includes the stretch test—the difference in distance between nipple and inframammary fold in relaxed position compared to distance between nipple and inframammary fold under full skin stretch, which should be less than 50% for successful treatment. The pinch test, measured at the expected border of the planned injection site, needs to be more than 2cm for treatment. Patients should also be assessed for ptosis—patients with nipple areolar complex below or at inframammary fold are less suitable for treatment.
Macrolane can be injected with local anaesthetic at the site of needle entry or via a tumescent technique into the subglandular pocket. Injection is performed using a 16 gauge (or wider) cannula via a single point of entry at the top of pectoralis major in the axillary line or distal to the inframammary fold.
The breast tissue is lifted and the cannula introduced into the plane between the glandular tissue and underlying pectoralis major muscle. The filler is slowly injected until the desired volume is reached—the average amount injected per breast is 100ml. It is important to assess the shape of the breast at intermittent intervals to ensure the correct size and shape is achieved. Any corrections can be made by massaging the breast at the end of the procedure to develop the final shape. Swelling, bruising, pain and erythema are common temporary side effects of treatment.
In a 12-month follow up of 24 women undergoing Macrolane augmentation, Per Heden demonstrated a patient satisfaction of 100% at six weeks, 95% at three months and 83% at six months. Independent and investigator assessed improvement corresponded to patient scores. This study group had a total of 60 adverse events in 20 patients, of which 43 were related to the product or injection technique and 86% were rated as mild to moderate in intensity.
The most commonly reported adverse event was capsular contracture, with eight Baker grade III events and two Baker grade IV. Eight events were treated by closed capsulotomy and the remaining two were managed conservatively. The second most commonly reported event was breast tenderness, which was mild to moderate in intensity and of approximately three days’ duration.
The British Association of Cosmetic Doctors audited Macrolane for breast augmentation in 2009. The incidence of complications reported can be seen in the table overleaf.
In addition to complications encountered in Per Heden’s study, a subset of patients (0.48%) undergo accelerated breakdown of the filler, losing more than 50% of product within six months. While the mechanism of this phenomenon has not been fully clarified, it is seen in patients who are typically very thin and have a high metabolic rate.
Macrolane offers a temporary, small to moderate increase in breast size but at considerable financial cost. It is suitable for a subset of women who do not want surgical augmentation and will be satisfied with a relatively small volume increase in breast size. The complications of migration and capsular contracture do occur and careful placement and good surgical technique are essential.
