Figure I   Figure II Breast Augmentation Surgical treatment of diseases of the breast and surgical treatment of cosmetic deformities of the breast comprises a large percentage of the total number of surgeries performed in the United States today. Such surgeries include both men and women and include surgery for treatment of inflammatory breast disease, neoplastic breast disease, and cosmetic deformities of the breast. I will limit my discussion to surgical treatment of cosmetic deformities of the breast but it should be born in mind that one out of nine women will have cancer of the breast at some time during their life and any cosmetic surgical procedure should take this high instance of breast cancer into consideration. Cosmetic procedures in women include breast augmentation, breast lift, breast reduction, and in men treatment of breast enlargement and gynecomastia. By far the most common procedure is that of breast augmentation. Indications for treatment are presence small breasts. This may come about as a result of failure to develop or may occur as the breasts atrophy following childbirth and advanced age. In either event, there may be a degree of ptosis (droopiness) which could make concomitant breast lift desirable. A certain degree of lifting of the breast occurs as the result of insertion of an implant. The larger the implant the greater the lift achieved. There are however limits to the amount of lifting which can be achieved by insertion of the implant and in some instances breast lift may also be required. There are several different kinds of breast lifts, some resulting in more scarring than others. Breast lifts and breast reductions can accomplish major changes in the shape and size of the breast, but all result in significant scarring. In most instances, the scar will be thin and flat and the color will be close to normal skin color. However, significant unsightly scars may form on the skin of the breasts and detract from an otherwise quite satisfactory cosmetic result. Unfortunately, the quality of the scar depends more upon the inherent healing capacity of the patient than upon the skill of the surgeon. Some patients form bad scars in spite of excellent surgical treatment. Figure II   Figure II Breast augmentation is possible without placing a scar on the breast. It is possible to insert implants through auxiliary incisions or as is my preference through an incision in the "belly button"- the transumbilical breast augmentation (TUBA). In this approach, the patient is anesthetized, an incision is made around the lip of the umbilicus, and a tunneling instrument is used to create a channel between the umbilical incision and the undersurface of the breast tissue. On the chest wall, under the breast tissue, a pocket is created and inspected by insertion of the endoscope. Any area of bleeding is electrocauterized, and the pocket is enlarged to accommodate an implant. The endoscope is removed. The implant is evacuated and rolled tightly into a cigar shape. A long fill tube is connected to the implant, and the implant is worked up through the channel to lie in position behind the breast tissue. The implant is filled with saline, the fill tube is removed and endoscopic inspection performed to confirm proper position.The small incision in the umbilicus is closed and an occlusive dressing applied. The patient is discharged after a short recovery. She is able to be up and active the day of surgery, and may even shower the night of surgery. Activities are restricted only by the degree of discomfort which in most cases is mild to moderate. A discussion of the various possible complications including the risk of the use of silicone is beyond the scope of this presentation. When I see a patient in consultation, I spend at least an hour with the patient and give them a voluminous packet of educational materials to take home. Suffice it to say that the major, real problem relative to breast augmentation is development of capsular contracture. A brief discussion of capsular contracture is follows: Whenever any foreign body is placed under the skin, whether it be the lead of a pencil,a pacemaker, a bullet, or a breast implant, scar tissue forms around the foreign body. This is the body's way of separating that foreign body from itself. In cases where the foreign body is solid, such as the pacemaker or bullet,no matter how dense the scar tissue becomes there is no significant effect.In the case of a breast implant, if a small or moderate amount of scar tissues present then no disturbing result occurs. If however, dense scar tissue forms around the implant then the implant can be deformed, some pain can occur and the breast will feel hard, and the implant may be drawn into an abnormal position. Why some women develop more scar tissue than others is unknown, and why one breast or the other may be involved but not both is unknown. Many theories have been advanced, and many attempts to decrease the chance of capsular contracture have been instituted. Nevertheless, some degree of capsular contracture may occur in up to 20% of patients. This sounds like a high percentage, and indeed it is, but capsular contracture is graded one, two, three, and four, and grades one and two usually require no surgical intervention. When treatment is instituted, it includes massage and anti-inflammatory medications. Often fully developed contracture is avoided. For this reason, close and frequent monitoring of the patient and early institution of treatment postoperatively is required. If a capsular contracture is more severe, it may require surgical excision, if there is pain and deformity. In that event, the capsule will be removed and a new implant inserted. Redevelopment of capsular contracture can indeed occur, but of course is not inevitable. Usually the onset of capsular contracture is fairly soon after insertion of the implants but it can occur even years later. Other complications of breast augmentation include bleeding, scarring, infection, deflation of the implant, change in nipple sensitivity, rippling of the implant, and palpability of the implant. These in aggregate are much less frequent than the development of capsular contracture. Capsular contracture is the most frequent serious complication and should be considered a very real threat, not to be taken lightly. It does occur and it does cause problems. Figures I and 2, 3, and 4 and postoperative pictures of patients having undergone transumbilical breast augmentation (TUBA). Note that there are no breast scars and the scar of the umbilicus is unobtrusive and easily hidden.

call: (404) 255-3555